Systems, methods and apparatuses for formation and insertion of tissue prosthesis

ABSTRACT

A tissue prosthesis insertion system includes a first assembly comprising a plurality of nested tubes, one of the tubes being a carrier tube which, in use, receives a component of a tissue prosthesis at a distal end of the carrier tube. A magnetic mount is carried at a proximal end of the first assembly. A second assembly is removably attachable to the first assembly. An attachment device is carried at a distal end of the second assembly, the attachment device being responsive to the magnetic mount of the first assembly, the magnetic mount and the attachment device carrying complementary engaging formations to facilitate hermetic sealing between the magnetic mount and the attachment device.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims priority to U.S. Provisional Application No.60/915,410, filed on May 1, 2007.

Additionally, each of the following applications are herein incorporatedby reference, in its entirety:

-   International Application No. PCT/AU2003/001289, filed on Sep. 30,    2003;-   Australian Provisional Application No. 2002951762, filed on Oct. 1,    2002;-   International Application No. PCT/AU2006/000267, filed on Mar. 1,    2006;-   Australian Provisional Application No. 2005900952, filed on Mar. 1,    2005;-   International Application No. PCT/AU2006/001176, filed on Aug. 15,    2006;-   U.S. Provisional Application No. 60/708,687, filed on Aug. 15, 2005;-   International Application No. PCT/AU2007/00001601 filed on Oct. 22,    2007:-   U.S. Provisional Application No. 60/867,574, filed on Nov. 28, 2006;-   International Application No. PCT/AU2007/001657, filed on Oct. 31,    2007:-   U.S. Provisional Application No. 60/915,410, filed on May 1, 2007;    and-   U.S. Provisional Application No. 60/971,633 filed on Sep. 12, 2007.

FIELD OF THE DISCLOSURE

The present disclosure generally relates to tissue prostheses and moreparticularly, the present disclosure relates to systems, methods, andapparatuses for formation and insertion of tissue prostheses.

BACKGROUND INFORMATION

Joints of the musculoskeletal system of the human or animal body rely onthe presence of healthy cartilaginous tissue for proper operation.Cartilaginous tissue can degenerate due to a number of causes, e.g., ageor injury. Degradation of the tissue can reach a point where movementcan cause severe discomfort and pain.

Degradation of tissue can occur in the spinal column. The spinal columncomprises a series of 26 mobile vertebral bones, or vertebrae, connectedby 75 stable articulations that control motion. The vertebrae aregenerally divided into posterior and anterior elements by thick pillowsof bone called pedicles. The anterior element of the vertebra is akidney shaped prism of bone with a concavity directed posteriorly andhas flat superior and inferior surfaces called end plates. Anintervertebral disc is sandwiched between adjacent pairs of vertebraeforming a joint between the adjacent pair of vertebrae. These discs areviscoelastic structures comprising a layer of strong, deformable, softtissue. The intervertebral discs are subjected to a considerable varietyof forces and moments resulting from the movements and loads of thespinal column. Each intervertebral disc has two components, being theannulus fibrosis surrounding a nucleus pulposus. The intervertebral disccooperates with end plates of the vertebrae between which it issandwiched.

The primary function of the nucleus pulposus of the disc is to give thedisc its elasticity and compressibility characteristics to assist insustaining and transmitting weight. The annulus fibrosis contains andlimits the expansion of the nucleus pulposus during compression and alsoholds together successive vertebrae, resisting tension and torsion inthe spine. The end plates of the vertebrae are responsible for theinflux of nutrients into the disc and the efflux of waste products fromwithin the disc.

With age or injury, a degenerative process of the disc may occur wherebyits structures undergo morphological and biological changes affectingthe efficiency with which the disc operates. Thus, the nucleus pulposusmay reduce in volume and dehydrate resulting in a load reduction on thenucleus pulposus, a loss in intradiscal pressure and, hence, additionalloading on the annulus fibrosis. In a normally functioning disc, theintradiscal pressure generated results in deformation of the end platesof the adjacent vertebrae generating the natural pumping action whichassists in the influx of the nutrients and the efflux of waste productsas stated above. A drop in intradiscal pressure therefore results inless end plate deformation. The nutrients supplied to the discal tissueare reduced and metabolic wastes are not removed with the sameefficiency. This contributes to a degenerative cascade.

Radial and circumferential tears, cracks and fissures may begin toappear within the annulus fibrosis. If these defects do not heal, someof the nuclear material may begin to migrate into the defects in theannulus fibrosis. Migration of the nuclear material into the annulusfibrosis may cause stretching and delamination of layers of the annulusfibrosis resulting in back pain due to stimulation of the sinu-vertebralnerve. An intervertebral disc without a competent nucleus is unable tofunction properly. Further, since the spine is a cooperative system ofelements, altering the structure and mechanics at one location of thespinal column may significantly increase stresses experienced atadjacent locations thereby further contributing to the degenerativecascade.

In the past, operative intervention has occurred to relieve lower backpain arising from intervertebral disc degeneration. Most of thisoperative intervention has been by way of a discectomy where leakingnuclear material is removed or, alternatively, fusion. The primarypurpose of a discectomy is to excise any disc material that is impingingon the spinal nerve causing pain or sensory changes. Fusion meanseliminating a motion segment between two vertebrae by use of a bonegraft and sometimes internal fixation. Biomechanical studies show thatfusion alters the biomechanics of the spine and causes increasedstresses to be experienced at the junction between the fused and unfusedsegments. This promotes degeneration and begins the degenerative cycleanew. Clearly, being an invasive operative procedure, fusion is a riskyprocedure with no guarantee of success.

Due to the minimal success rate of these previous procedures, as well astheir inability to restore complete function to the spinal column,alternative treatments have been sought in the form of artificial discreplacements. Theoretical advantages of artificial disc replacement overa fusion procedure include preservation or restoration of segmentalmotion in the spine, restoration of intervertebral architecture andforaminal height, sparing of adjacent segments of the spine fromabnormal stresses and restoration of normal biomechanics across thelumbar spine. The established artificial disc replacement procedureconsists of techniques that require a surgical incision on the abdomen,retraction of large blood vessels, a total excision of the anteriorlongitudinal ligament, anterior and posterior annulus along with thenucleus and near total removal of the lateral annulus and implantationof an articulated prosthesis. This is a major spinal columnreconstruction operation carried out by a very invasive technique.

Accordingly, the present inventors has observed that there is a need forsurgical procedures, methods, and/or systems which, as far as possible,restore the biomechanics of joints such as those between adjacentvertebrae of the spine by the provision of a tissue prosthesis mimickingnatural, healthy cartilaginous tissue as well as a means of carrying outthe surgical procedure in a minimally invasive manner and/orpercutaneous manner.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1-8 show schematic illustrations of various steps of a method, inaccordance with certain exemplary embodiments disclosed herein, forforming a tissue prosthesis in situ at a site in a patient's body;

FIG. 9 shows a schematic illustration of a delivery device for use inaccordance with certain exemplary embodiments disclosed herein;

FIG. 10 shows a schematic, sectional side view of part of equipment, inaccordance with certain exemplary embodiments disclosed herein, forforming a tissue prosthesis, in situ at a site in a patient's body;

FIG. 11 shows a schematic, sectional side view of the equipment inaccordance with certain exemplary embodiments disclosed herein;

FIG. 12 shows a schematic, side view and end view of part of theequipment in accordance with certain exemplary embodiments disclosedherein:

FIG. 13 shows a sectional side view of an envelope, attached to adelivery device, the envelope forming part of a tissue prosthesis, inaccordance with certain exemplary embodiments disclosed herein;

FIG. 14 shows a sectional side view of another mounting of the envelopeon the delivery device in accordance with certain exemplary embodimentsdisclosed herein;

FIGS. 15-17 show different shapes of envelopes for use in the tissueprosthesis in accordance with certain exemplary embodiments disclosedherein;

FIG. 18 shows a plan view of another embodiment of equipment for forminga tissue prosthesis, in situ, at a site in a patient's body inaccordance with certain exemplary embodiments disclosed herein;

FIG. 19 shows a sectional side view taken along line XIX-XIX in FIG. 18in accordance with certain exemplary embodiments disclosed herein:

FIG. 20 shows, on an enlarged scale, a sectional side view of the partof the equipment encircled by circle ‘A’ in FIG. 19 in accordance withcertain exemplary embodiments disclosed herein:

FIG. 21 shows, on an enlarged scale, a sectional side view of the partof the equipment encircled by circle ‘B’ in FIG. 19 in accordance withcertain exemplary embodiments disclosed herein;

FIG. 22 shows a sectional side view of yet a further embodiment ofequipment for forming a tissue prosthesis, in situ, at a site in apatient's body in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 23 shows on an enlarged scale, a sectional side view of the part ofthe equipment encircled by circle ‘C’ in FIG. 22 in accordance withcertain exemplary embodiments disclosed herein;

FIG. 24 shows on an enlarged scale, a sectional side view of the part ofthe equipment encircled by circle ‘D’ in FIG. 22 in accordance withcertain exemplary embodiments disclosed herein:

FIG. 25 shows a plan view of a first assembly of a tissue prosthesisinsertion system in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 26 shows a sectional side view of the first assembly of the systemof FIG. 25 taken along line II-II in FIG. 25 in accordance with certainexemplary embodiments disclosed herein;

FIG. 27 shows a sectional side view, on an enlarged scale, of the partof the first assembly surrounded by circle ‘A’ in FIG. 26 in accordancewith certain exemplary embodiments disclosed herein:

FIG. 28 shows a sectional side view, on an enlarged scale, of the partof the first assembly surrounded by circle ‘B’ in FIG. 26 in accordancewith certain exemplary embodiments disclosed herein;

FIG. 29 shows a plan view of an assembly of the tissue prosthesisinsertion system in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 30 shows a sectional side view of the assembly of the system takenalong line VI-VI in FIG. 29 in accordance with certain exemplaryembodiments disclosed herein;

FIG. 31 shows a sectional side view, on an enlarged scale, of the partof the assembly surrounded by circle ‘C’ in FIG. 30 in accordance withcertain exemplary embodiments disclosed herein;

FIG. 32 shows a sectional side view, on an enlarged scale, of the partof the assembly surrounded by circle ‘D’ in FIG. 30 in accordance withcertain exemplary embodiments disclosed herein:

FIG. 33 shows a plan view of a valve member forming part of a tissueprosthesis of the system in accordance with certain exemplaryembodiments disclosed herein;

FIG. 34 shows an end view of the valve member in accordance with certainexemplary embodiments disclosed herein;

FIG. 35 shows a sectional side view of the valve member taken along lineXI-XI in FIG. 34 in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 36 shows a schematic side view of a working cannula of the assemblyin position after formation of the tissue prosthesis in accordance withcertain exemplary embodiments disclosed herein;

FIG. 37 shows a schematic side view of a further part of the systeminserted into the cannula to complete formation of the tissue prosthesisin accordance with certain exemplary embodiments disclosed herein;

FIGS. 38A and B shows a sectional side view of a prosthesis deliverysystem in accordance with certain exemplary embodiments disclosedherein:

FIG. 39 shows, on an enlarged scale, a sectional side view of theencircled portion of the system marked ‘A’ in FIG. 38 of the drawings inaccordance with certain exemplary embodiments disclosed herein:

FIG. 40 shows a component of a prosthesis delivery system in accordancewith certain exemplary embodiments disclosed herein;

FIG. 41 shows a sectional side view of a part a prosthesis deliverysystem including the component of FIG. 40 in accordance with certainexemplary embodiments disclosed herein:

FIG. 42 shows a sectional side view of a part of a further embodiment ofa prosthesis delivery system including the component of FIG. 40 inaccordance with certain exemplary embodiments disclosed herein:

FIGS. 43 a, 43 b and 43 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein;

FIGS. 44 a, 44 b and 44 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein:

FIGS. 45 a, 45 b and 45 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein;

FIGS. 46 a, 46 b and 46 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein:

FIGS. 47 a, 47 b and 47 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein;

FIGS. 48 a, 48 b and 48 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein;

FIGS. 49 a, 49 b and 49 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein;

FIGS. 50 a, 50 b and 50 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein:

FIGS. 51 a, 51 b and 51 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein;

FIGS. 52 a, 52 b and 52 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein;

FIGS. 53 a, 53 b and 53 c show, respectively, front, side and plan viewsof an intervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein;

FIG. 54 shows a schematic side view of an intervertebral disc implant ina first configuration, in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 55 shows a schematic plan view of the implant of FIG. 54 in asecond configuration in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 56 shows a schematic side view of an intervertebral disc implant ina first configuration, in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 57 shows a schematic plan view of the implant of FIG. 56 in asecond configuration in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 58 shows a schematic side view of an intervertebral disc implant ina first configuration, in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 59 shows a schematic plan view of the implant of FIG. 58, in use,in a second configuration in accordance with certain exemplaryembodiments disclosed herein;

FIG. 60 shows a schematic plan view of an intervertebral disc implant,in accordance with certain exemplary embodiments disclosed herein:

FIG. 61 shows a schematic plan view of an intervertebral disc implant,in accordance with certain exemplary embodiments of the inventionsdisclosed herein;

FIG. 62 shows a schematic three dimensional view of the implant of FIG.61 in accordance with certain exemplary embodiments disclosed herein;

FIG. 63 shows a schematic three dimensional view of an intervertebraldisc implant, in accordance with certain exemplary embodiments disclosedherein;

FIG. 64 shows a schematic three dimensional view of an intervertebraldisc implant, in accordance with certain exemplary embodiments disclosedherein;

FIG. 65 shows a three dimensional view of an intervertebral discimplant, in accordance with certain exemplary embodiments disclosedherein;

FIG. 66 shows a sectional side view of the implant of FIG. 65 inaccordance with certain exemplary embodiments disclosed herein;

FIG. 67 shows a three dimensional view of the implant of FIG. 65, inaccordance with certain exemplary embodiments disclosed herein;

FIG. 68 shows a schematic three dimensional view of an intervertebraldisc implant, in accordance with certain exemplary embodiments disclosedherein;

FIG. 69 shows a schematic, sectional plan view of an intervertebral discimplant, in accordance with certain exemplary embodiments disclosedherein:

FIG. 70 shows sectional end view taken along line A-A in FIG. 69 inaccordance with certain exemplary embodiments disclosed herein;

FIG. 71 shows a schematic, sectional three dimensional view of anintervertebral disc implant, in accordance with certain exemplaryembodiments disclosed herein;

FIG. 72 shows, on an enlarged scale, the detail encircled by “A” in FIG.71 in accordance with certain exemplary embodiments disclosed herein;

FIG. 73 shows the detail of FIG. 72 in a collapsed configuration inaccordance with certain exemplary embodiments disclosed herein:

FIG. 74 shows a three dimensional view of a system, in accordance withcertain exemplary embodiments disclosed herein, for implanting anintervertebral disc implant;

FIG. 75 shows, on an enlarged scale, a three dimensional view of thesystem of FIG. 74 in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 76 shows a schematic, sectional side view of an introducer for asystem, in accordance with certain exemplary embodiments disclosedherein, for implanting an intervertebral disc implant.

FIGS. 77-79 illustrate, schematically, various stages of the use of anembodiment of equipment, in accordance with certain exemplaryembodiments disclosed herein, for preparing a site for the implantationof a tissue prosthesis;

FIGS. 80-85 illustrate, schematically, various stages of the use ofanother exemplary embodiment of equipment, in accordance with certainexemplary embodiments disclosed herein, for preparing a site for theimplantation of a tissue prosthesis;

FIG. 86 illustrates spinal disk load vs. displacement as determined inaccordance with a finite element analysis of an exemplary implant:

FIG. 87 illustrates a sectional view of a ball valve inside an envelopein an open position in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 88 illustrates a sectional view of a ball valve inside an envelopein a closed position in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 89 illustrates a sectional view of a umbrella valve inside anenvelope in an open position in accordance with certain exemplaryembodiments disclosed herein:

FIG. 90 illustrates a sectional view of a umbrella valve inside anenvelope in a closed position in accordance with certain exemplaryembodiments disclosed herein;

FIG. 91 illustrates an exemplary valve-like configuration where thediameter gradually decreases to limit backflow in accordance withcertain exemplary embodiments disclosed herein;

FIG. 92 illustrates a means of sealing through an O-ring (the crosssection of the O-ring can be seen in the close up view) in accordancewith certain exemplary embodiments disclosed herein;

FIG. 93 illustrates a means of sealing through a luer lock in accordancewith certain exemplary embodiments disclosed herein:

FIG. 94 illustrates a means of sealing through a luer slip or luerfitting (taper fit) in accordance with certain exemplary embodimentsdisclosed herein;

FIG. 95 illustrates an exemplary priming means in which air is ventedthrough a slit as the biomaterial primes the tube in accordance withcertain exemplary embodiments disclosed herein;

FIG. 96 illustrates a single lumen delivery means where the air ventsaround the space between the filler tube and the valve-like structure inaccordance with certain exemplary embodiments disclosed herein; and

FIG. 97 illustrates an end on view of the space around the tube when ithas been pushed into the valve in accordance with certain exemplaryembodiments disclosed herein.

DETAILED DESCRIPTION

In certain exemplary embodiments disclosed herein, there may be providedmethods of forming a tissue prosthesis in situ at a site in a patientsbody, that comprise accessing the site in the patient's body; ifnecessary, removing tissue from the site to form a cavity; inserting anenvelope of a biologically inert, elastically deformable material intothe cavity; charging a filler material, in a fluent state, into theenvelope to cause the envelope to expand and, if necessary, stretch andconform to the shape of the cavity, and allowing the filler material tocure, the filler material being of the same class of material as theenvelope so that, when the filler material has cured, a unifiedprosthesis is formed. In some aspects, these methods may be carried outusing minimally invasive techniques. In some aspects, these methods maybe carried out using percutaneous techniques. In some aspects, thesemethods may be carried out using a combination of minimally invasive andpercutaneous techniques.

In certain exemplary embodiments disclosed herein, there may be providedmethods of forming a tissue prosthesis in situ at a site in a patient'sbody, that comprise means for accessing the site in the patient's body:if necessary, means for removing tissue from the site to form a cavity;means for inserting an envelope of a biologically inert, elasticallydeformable material into the cavity; means for charging a fillermaterial, in a fluent state, into the envelope to cause the envelope toexpand and or stretch, if necessary and conform to the shape of thecavity; and means for allowing the filler material to cure, the fillermaterial being of the same class of material as the envelope so that,when the filler material has cured, a unified prosthesis is formed. Insome aspects, these methods may be carried out using minimally invasivetechniques. In some aspects, these methods may be carried out usingpercutaneous techniques. In some aspects, these methods may be carriedout using a combination of minimally invasive and percutaneoustechniques.

In certain exemplary embodiments disclosed herein, the methods mayinclude accessing the site percutaneously in a surgical procedure thatis less invasive than conventional procedures. Hence, the method may beused to perform less invasive intervertebral disc nucleus replacementand the method may comprise forming an aperture in an annulus fibrosisof the disc percutaneously; extracting a nucleus pulposus of the disc toform a disc cavity bounded by the annulus fibrosis of the disc and endplates of vertebrae between which the disc is located; inserting theenvelope, in a first state, into the cavity through the aperture;charging the filler material into the envelope to cause the envelope toexpand and conform to the shape of the disc cavity; allowing the fillermaterial to cure to form, together with the envelope, the substantiallyunified prosthesis; and occluding the aperture.

In certain exemplary embodiments disclosed herein, there may be providedmethods of preparing a first assembly of a tissue prosthesis system forinsertion into a patient's body, the methods comprising providing afirst assembly which comprises a plurality of nested tubes, one of thetubes being a carrier tube; mounting a component of the prosthesis on adistal end of the carrier tube, the component being of an elasticallydeformable material; inserting a stiffening member into the firstassembly so that the stiffening member extends into an interior of thecomponent and causing a proximal end of the stiffening member to engagea proximal end of the first assembly; attaching a withdrawing device tothe first assembly so that the withdrawing device is in fluidcommunication, at least with the interior of the component; andoperating the withdrawing device to reduce the pressure, at least in theinterior of the component to cause the component to collapse about thestiffening member.

In certain embodiments disclosed herein, there may be provided methodsof preparing a first assembly of a tissue prosthesis system forinsertion into a patient's body, the methods comprising means forproviding a first assembly which comprises a plurality of nested tubes,one of the tubes being a carrier tube: means for mounting a component ofthe prosthesis on a distal end of the carrier tube, the component beingof an elastically deformable material; means for inserting a stiffeningmember into the first assembly so that the stiffening member extendsinto an interior of the component and causing a proximal end of thestiffening member to engage a proximal end of the first assembly; meansfor attaching a withdrawing device to the first assembly so that thewithdrawing device is in fluid communication with the interior of thecomponent; and means for operating the withdrawing device to reduce thepressure in the interior of the component to cause the component tocollapse about the stiffening member.

In certain exemplary embodiments of the disclosed herein, there may beprovided methods of forming a tissue prosthesis at a site in a patient'sbody, the methods comprising providing a first assembly comprising aplurality of nested tubes, one of the tubes being a carrier tube with acomponent of the prosthesis carried at a distal end of the carrier tube:inserting the first assembly into a cannula placed in the patient'sbody, whereby the working cannula or cannula provides percutaneousaccess to the disc; engaging (e.g. magnetically attaching) a secondassembly to a proximal end of the first assembly; and charging a fillermaterial from the second assembly into the component and allowing thefiller material to set.

In certain exemplary embodiments disclosed herein, there may be providedmethods of implanting an intervertebral disc implant into anintervertebral disc, the methods comprising percutaneously performing anucleotomy on the disc to remove a at least a portion of the nucleuspulposus of the disc to create a volume, inserting an envelope of theimplant into the volume; charging an interior of the envelope withfiller material in a manner to allow the envelope to expand to conformsubstantially to the volume, and causing the interior of the envelope tobe closed off to retain the filler material within the envelope. Thefiller material may be selected to mimic, enhance or at least restore asmuch as possible the natural biomechanical characteristics of thenucleus pulposus of the disc. In certain embodiments, the fillermaterial (e.g., the implant) may cooperate with the annulus to restoreat least a portion of the natural biomechanical characteristics of thedisc.

In certain embodiments, the various methods of implanting anintervertebral disc implant described throughout the specification maybe performed in less time than prior art methods. For example, incertain embodiments, the method may be performed in less than 30minutes, or less than 20 minutes, or less than 15 minutes, or less than10 minutes. In certain embodiments, the method, excluding the chargingof the interior of the envelope, may be performed in less than 30minutes, or less than 20 minutes, or less than 15 minutes, or less than10 minutes. In certain embodiments, the method, excluding the nucleotomyprocedure may be performed in less than 30 minutes, or less than 20minutes, or less than 15 minutes, or less than 10 minutes.

In certain exemplary embodiments disclosed herein, there may be providedmethods of implanting an intervertebral disc implant into anintervertebral disc, the methods comprising means for accessing the discpercutaneouslty using for example a working cannula; means forpercutaneously performing a nucleotomy on the disc to remove at least aportion of the nucleus pulposus of the disc to create a volume; meansfor inserting an envelope of the implant into the volume; means forcharging an interior of the envelope with filler material in a manner toallow the envelope to expand to conform substantially to the volume; andmeans for causing the interior of the envelope to be closed off toretain the filler material within the envelope, the filler materialbeing selected to mimic natural biomechanical characteristics of thenucleus pulposus of the disc.

In certain exemplary embodiments disclosed herein, there is providedmethods of implanting an intervertebral disc implant into anintervertebral disc, the methods including a method of accessing thedisc percutaneously using for example a working cannula, a method forremoving at least a portion of the nucleus pulposus of the disc tocreate a volume; inserting at least one envelope into the volume;charging an interior of the at least one envelope with material in amanner to allow the at least one envelope to expand to substantiallyfill the volume, or partially fill the volume; and causing the interiorof the envelope to be closed off to retain the material, the fillermaterial being selected to at least partially mimic characteristics ofthe nucleus pulposus of the disc.

In certain exemplary embodiments disclosed herein, there is providedmethods of implanting an intervertebral disc implant into anintervertebral disc, the methods including means for performing anucleotomy on the disc to remove a nucleus pulposus of the disc tocreate a volume: means for inserting an envelope of the implant into thevolume: means for charging an interior of the envelope with fillermaterial in a manner to allow the envelope to expand to conformsubstantially to the volume; and means for causing the interior of theenvelope to be closed off to retain the filler material within theenvelope, the filler material being selected to mimic naturalbiomechanical characteristics of the nucleus pulposus of the disc.

In certain exemplary embodiments disclosed herein, there is providedmethods of implanting an intervertebral disc implant into anintervertebral disc, the methods including percutaneously performing anucleotomy on the disc to remove a nucleus pulposus of the disc tocreate a volume; inserting an introducer into an opening formed in anannulus of the disc; and introducing into the volume, via theintroducer, at least one element which changes from a firstconfiguration, in which the at least one element is able to be insertedinto the introducer, to a second configuration in which the at least oneelement conforms substantially to the volume.

In certain exemplary embodiments disclosed herein, devices may beprovided for forming a tissue prosthesis in situ at a site in apatient's body, the devices may comprise a delivery device displaceablyreceivable in a lumen of an introducer, the delivery device defining apassageway; an envelope carried at a distal end of the delivery device,the envelope being of a biologically inert, elastically deformablematerial capable of being expanded to conform to an interior surface ofa cavity formed at the site; and a supply of a filler materialchargeable in a fluent state into the envelope through the passageway ofthe delivery device, the filler material being of the same class ofmaterial as the envelope to form, when cured, together with theenvelope, a unified prosthesis.

In certain exemplary embodiments disclosed herein, devices may beprovided for forming a tissue prosthesis in situ at a site in apatient's body, the devices may comprise a tubular delivery device, thedelivery device defining a passageway, an envelope of the prosthesisbeing mountable to a distal end of the delivery device to be received ina cavity at the site: a filler member receivable in the passageway ofthe delivery device, the filler member being receivable with clearancein the passageway to define a gap to enable fluid to be manipulated,displaced, or evacuated at least from the envelope; and a removalmechanism carried by the delivery device for enabling the envelope to beremoved from the delivery device after the envelope has been chargedwith filler material via the filler member.

In certain exemplary embodiments disclosed herein, devices may beprovided for forming a tissue prosthesis in situ at a site in apatient's body, the devices may comprise a means for tubular deliverydevice, the delivery device defining a passageway, an envelope of theprosthesis being mountable to a distal end of the delivery device to bereceived in a cavity at the site; a filler member receivable in thepassageway of the delivery device, the filler member being receivablewith clearance in the passageway to define a gap to enable fluid to beevacuated at least from the envelope; and a means for a removalmechanism carried by the delivery device for enabling the envelope to beremoved from the delivery device after the envelope has been chargedwith filler material via the filler member.

In certain exemplary embodiment disclosed herein, devices may beprovided for forming a tissue prosthesis in situ at a site in apatient's body, the devices may comprise a tubular delivery device, thedelivery device defining a passageway, an envelope of the prosthesisbeing mountable to a distal end of the delivery device to be received ina cavity at the site; a stiffening element arranged, or means forproviding a stiffening element, to project from a distal end of thedelivery device with the envelope, in use, being received over thestiffening element to be supported by the stiffening element; and aremoval mechanism carried by the delivery device for enabling theenvelope to be removed from the delivery device after the envelope hasbeen charged with filler material via the filler member.

In certain exemplary embodiment disclosed herein, tissue prosthesisinsertion systems may be provided which include a first assemblycomprising a plurality of nested tubes, one of the tubes being a carriertube which, in use, receives a component of a tissue prosthesis at adistal end of the carrier tube; a magnetic mount carried at a proximalend of the first assembly: a second assembly removably attachable to thefirst assembly; and an attachment device carried at a distal end of thesecond assembly, the attachment device being responsive to the magneticmount of the first assembly, the magnetic mount and the attachmentdevice carrying complementary engaging formations to facilitate sealingbetween the magnetic mount and the attachment device. In certainembodiments, the second assembly may have the magnetic mount where thefirst assembly has the engaging member which is sealingly responsive tothe magnetic mount of the second assembly.

In certain exemplary embodiment disclosed herein, tissue prosthesisinsertion systems may be provided which include an assembly comprising aplurality of nested tubes, one of which is a carrier tube for carrying acomponent of a tissue prosthesis at its distal end and another of whichis a filler tube received with clearance in the carrier tube to define apassage between the filler tube and the carrier tube, the proximal endof the filler tube and the proximal end of the carrier tube being insealing engagement; and a withdrawing device attachable to the assemblyso that, when the withdrawing device and material dispenser is attachedand the component of the tissue prosthesis is mounted on the distal endof the carrier tube, a closed system is formed which allows thewithdrawing device to be used to increase the volume of the closedsystem to form a low pressure region at least in the component.

In certain exemplary embodiment disclosed herein, tissue prosthesisinsertion systems may be provided which include a working cannula foraccessing a site in a patient's body percutaneously, in a less invasivemanner for carrying out a tissue prosthesis insertion procedure at thesite; and an obturating device receivable in the cannula for tamping apart of a tissue prosthesis into position after formation of the tissueprosthesis.

The obturating device may comprise a blunt-ended rod slidably receivablein the working cannula.

In certain exemplary embodiment disclosed herein, tissue prosthesiscomponents may be provided which include an envelope of an elasticallydeformable material, the envelope defining an access opening: and a flowcontrol member arranged in the access opening, the flow control memberbeing configured to permit withdrawal of fluid from an interior of theenvelope prior to filling the envelope with a filler material.

In certain exemplary embodiment disclosed herein, prosthesis deliverysystems may be provide which includes a plurality of nested tubes, anoutermost tube of which functions as a cannula in which the remainingtubes are received, the remaining tubes forming part of a prosthesisdelivery apparatus, a wall portion of at least one of the tubes having achange in diameter along its length to mate with a corresponding part ofa dispensing arrangement for use with the prosthesis delivery apparatus.

In certain exemplary embodiments disclosed herein, systems are providedwhich include a plurality of tubes, wherein an outermost tube functionsas a cannula in which the remaining tubes are received, the remainingtubes forming part of a prosthesis delivery apparatus, a wall portion ofat least one of the tubes having a change in diameter along its lengthto mate with a corresponding part of a dispensing arrangement for usewith the prosthesis delivery apparatus.

In some exemplary embodiments, the prosthesis delivery devices mayinclude at least one carry tube which may carry at least one componentof the prosthesis on its distal end and at least one filler tubereceivable in the carrier tube for charging a filler material into thecomponent when the component is located at the desired location. Theprosthesis delivery apparatus may include a connector for connection toa withdrawal device to enable fluid (e.g., air or gas) to be manipulated(e.g., withdrawn) from the component during formation of the prosthesisin situ, the connector being arranged, in use, at a proximal end of theprosthesis delivery apparatus.

In some exemplary embodiments, the prosthesis delivery apparatus mayinclude a displacement device for displacing the component of theprosthesis after it has been charged with the filler material. Thedisplacement device may be a further tube mounted about the carriertube.

In some exemplary embodiments, the prosthesis delivery apparatus mayinclude at least one cover tube to cover the component of theprosthesis, the at least one cover tube fitting over the at least onecarrier tube. The at least one cover tube may include a resilientlyflexible distal portion to accommodate the component of the prosthesis.In certain embodiments, the at least one cover tube may be received overthe displacement device/tube which is mounted about the carrier tube.

In some exemplary embodiments, a wall portion of each of the tubes has achange in diameter along its length. In some exemplary embodiments, thechange in diameter along the length of each tube may be provided by aflared wall portion of each tube.

In some exemplary embodiments, the systems may include a manipulatingarrangement for effecting manipulation of the tubes located within thecannula. The manipulating arrangement may include a rupturing mechanismfor rupturing the cannula for removal. The rupturing mechanism maycomprise a plurality of spaced zones of weakness in a wall of the tubeof the cannula and a gripping device arranged at a proximal end of thetube of the cannula. The gripping device may comprise a plurality ofoutwardly extending tabs which are pulled outwardly to cause rupturingof the zones of weakness of the cannula to facilitate withdrawal of thecannula after placement and positioning of the component of theprosthesis in the cavity or after formation and/or setting of theprosthesis.

In some exemplary embodiments, the systems may include the dispensingmechanism, the dispensing mechanism including a tubular element having adistal end which corresponds with and mates with that part of the wallportion of the at least one tube having the change in diameter. Thenested tubes may be configured to extend proximally of the distal end ofthe element to overlie the element. With this arrangement, the length ofthe unsupported ends of the tubes is shortened thereby improving therigidity of the tubes and the stability of the system. In addition, thebalance of the system is improved rendering it easier for the clinicianto control the system. This overall reduction in the length of thedelivery system may also result in a reduction in the pressure requiredto deliver the filler material to the envelope component of theprosthesis.

The dispensing mechanism may include a dispenser to which the element isattachable. The element may be a static mixer.

In certain exemplary embodiment disclosed herein, prosthesis deliverysystems are provided which include a plurality of nested tubes, one tubebeing a carrier tube which carries at least a component of a prosthesisat its distal end and another tube constituting a delivery tube fordelivering the nested tubes to a site at a patient's body; and a covertube forming part of the nested tubes, the cover tube being arrangedoutwardly of the carrier tube to cover the component when the carriertube is inserted into the delivery tube to protect the component.

In certain exemplary embodiments disclosed herein, there is provided anintroducer for introducing an intervertebral disc implant into a discthat has undergone a nucleotomy, the introducer including at least twosleeves arranged telescopically with respect to each other; and adisplacement mechanism arranged on an operatively inner surface of aninnermost one of the sleeves for assisting in displacing filler materialalong the sleeves into an interior of the disc, in use.

The displacement mechanism may comprise a ratchet arrangement for urgingthe filler material along the sleeve.

In certain embodiments disclosed herein, equipment may be provided forpreparing a site for the implantation of tissue prosthesis. Theequipment may include, for example a conduit assembly; an elasticallystretchable and/or an inflatable member receivable on a distal end ofthe conduit assembly, the inflatable member being positioned, in use, ata site in a patient's body at which a tissue prosthesis is to beimplanted: and a plurality of fluid dispensers connectable to theconduit assembly to communicate with the inflatable member, operation ofthe fluid dispensers manipulating the inflatable member to facilitateformation of the tissue prosthesis at the site.

Manipulating the inflatable member may comprise priming the inflatablemember to receive a volume of fluid (e.g., a liquid or gas) to determinea size of the site. Still further, manipulating the inflatable membermay comprise cyclically inflating and deflating the inflatable member tocondition tissue surrounding the site.

The equipment may include a monitoring mechanism for monitoring a volumeof fluid dispensed by a selected one or more of the fluid dispensersinto the inflatable member to determine a size of a cavity at the siteto be filled by the tissue prosthesis. In this manner, the inflatablemember may act as a mock implant and may also determine the relativeposition of the implant as well. In certain exemplary embodiments, themonitoring device may be a pressure transducer. It will, however, beappreciated that other transducers such as force transducers, straingauges, or the like could be employed to function as an end-pointmonitor. Alternatively, in embodiments where at least the volume ofnucleus removed, or the volume created by the nucleotomy procedure, isreplaced. Accordingly, the device may allow the volume to be measuredwhich allows the surgeon to gauge the required volume of biomaterial tobe dispensed into the envelope component of the implant.

In certain embodiments, the conduit assembly may comprise at least onetube on which the inflatable member is mountable with a branchedconnector being carried at a proximal end of the at least one tube, oneof the fluid dispensers being connectable to each branch of theconnector. The branched connector may be for example, a Y connector or aT connector.

In certain exemplary embodiments, the conduit assembly may comprise apair (e.g., at least 2, 3, 4, 5, 6, 7, 8, etc.) of nested tubes, anouter tube being a carrier tube on which the inflatable member iscarried and an inner tube being a fluid delivery tube for dispensing avolume of fluid from one of the dispensers into the interior of thetube. In certain embodiments, at least one of the tubes may extend, inuse, to a distal end of the inflatable member and the tube may have anaperture defined in it which facilitates fluid communication between aninterior of the inflatable member and an interior of the tube or tubes.The at least one tube extending into the inflatable member may, incertain embodiments, serve to allow the inflatable member to becollapsible about the tube and more easily introduced percutaneously orminimally invasively through the working cannula.

In another exemplary embodiment, the conduit assembly may comprise asingle tube on a distal end of which the inflatable member is carried. Aflow control member may be received in communication with an interior ofthe tube for placing a selected one of the fluid dispensers in fluidcommunication with the interior of the tube and hence the interior ofthe inflatable member as desired. Similar to other exemplaryembodiments, the tube may extend, in use, to a distal end of theinflatable member and have an aperture defined in it which facilitatesfluid communication between an interior of the inflatable member and aninterior of the tube.

In certain embodiments, the flow control member may be a device whichcontrols the direction and flow of fluid. This can be, for example, a3-way stopcock, or it can be a valve which opens up when the fluiddispenser is engaged, and shuts off when the fluid dispenser isdisengaged (e.g., a duck bill valve). For example, with a duck billvalve, when the fluid dispenser is engaged, the tip of the fluiddispenser pushes open the leaflets of the valve, placing the interior ofthe tubes and inflatable component in fluid communication with the fluiddispenser. When the fluid dispenser is disengaged, the leaflets of thevalve. Such an apparatus using this form of valve system can omit theneed for the dual syringe system because a single syringe can be used toprime the system and any air or gas or other unwanted fluids which aredisplaced from within the system and into the syringe can be purged byremoving the syringe from the rest of the apparatus and purged bymanipulating the piston of the syringe. In the meantime, the fluidwithin the system is maintained within the system because of the valvewhich has closed off to substantially seal in the fluid which has beenused to displace the unwanted air, gas or other fluid which wasoriginally within the system.

At least one of the fluid dispensers may be a reciprocally operabledevice such as for example, a syringe.

In certain exemplary embodiments disclosed herein, there may be providedmethods of preparing a site for the implantation of tissue prosthesis.The methods may include inserting a member into a cavity at a tissuesite to be prepared; priming the member; and inflating the member atleast once with a volume of fluid to determine a size of the cavity.

In certain exemplary embodiments disclosed herein, there may be providedmethods of preparing a site for the implantation of tissue prosthesis.The methods may include means for inserting an inflatable member into acavity at a tissue site to be prepared, means for priming the inflatablemember; and means for inflating the inflatable member at least once witha volume of fluid to determine a size and/or position of the cavity.

The method may include priming the inflatable member prior to insertinginto the cavity which may entail priming the inflatable member prior toinserting the inflatable member into the patient's body. In certainexemplary embodiments, the method may include inflating and deflatingthe inflatable member a number of times to condition tissue surroundingthe cavity. In certain exemplary embodiment, the method may includemonitoring a predetermined parameter to determine the quantity of fluiddispensed into the inflatable member to fill the cavity.

The method may include means for priming the inflatable member prior toinserting into the cavity which may entail priming the inflatable memberprior to inserting the inflatable member into the patient's body. Incertain exemplary embodiments, the method may include means forinflating and deflating the inflatable member a number of times tocondition tissue surrounding the cavity. In certain exemplaryembodiments the method may include means for monitoring a predeterminedparameter to determine the quantity of fluid dispensed into theinflatable member to fill the cavity.

In certain exemplary embodiments disclosed herein, tissue prostheses areprovided which comprise at least one envelope of a biologically inert,elastically deformable material capable of being expanded to conform toan interior surface of a cavity formed at a site in a patient's body;and a filler material received in a fluent state in the at least oneenvelope, the filler material being of the same class of material as theat least one envelope to form, when cured, together with the envelope, aunified, or substantially unified, structure.

In certain exemplary embodiments disclosed herein, tissue prostheses areprovided which comprise an envelope of a foraminous, chemically inertmaterial shaped to conform to an interior surface of a cavity formed ata site in a patient's body in which the envelope is to be placed, and afiller material received in a fluent state in the envelope, the fillermaterial being of an elastomeric material which, prior to being cured,is urged into foramens of the envelope to form an integrated structurewhich inhibits relative movement between the envelope and the fillermaterial, in use, and once the filler material has cured.

In certain exemplary embodiments, there is provided an intervertebraldisc implants which includes an envelope constructed of at least onestretchable and/or elastically deformable elastomeric material, theenvelope including an attaching formation for attachment to anintroducer to enable the envelope, in a first state, to be introducedinto a volume of an intervertebral disc that has undergone a nucleotomy;and a filler material receivable in the envelope via the introducer tocause the envelope to expand elastically to conform substantially to thevolume in which the envelope is received, in use.

According to certain exemplary embodiments, there is provided anintervertebral disc implant which includes a first object constructed ofat least one stretchable and/or elastically deformable elastomericmaterial, the first object being in communication with second object forattachment to a third object to enable the first object, in a firststate, to be introduced into a volume of an intervertebral disc that hasundergone a nucleotomy; and a material receivable in the first objectvia the second object which results in expansion, or partial expansionof the first object such that the first object substantially conforms tothe volume in which the first object is received, in use.

According to certain exemplary embodiments, there is provided anintervertebral disc implant which includes an envelope constructed of atleast one stretchable and/or elastically deformable elastomericmaterial, the envelope including means for attaching an introducer toenable the envelope, in a collapsed state, to be introduced into avolume of an intervertebral disc that has undergone a nucleotomy; andmeans for introducing a filler material into the envelope via theintroducer to cause the envelope to expand elastically to conformsubstantially to the volume in which the envelope is received, in use.

In certain exemplary embodiments, there is provided an intervertebraldisc implant which includes an envelope, the envelope including anattaching formation for attachment to an introducer to enable theenvelope, in a collapsed state, to be introduced into a volume of anintervertebral disc that has undergone a nucleotomy; and a fillermaterial receivable in the envelope after placement of the envelope inthe volume of the disc, in use, to cause expansion of the envelope toconform to the volume, the filler material comprising a plurality ofdiscrete, elongate elements introducible, via the introducer, into aninterior of the envelope.

In certain exemplary embodiments, there is provided an intervertebraldisc implant which comprises an envelope receivable in a volume of anintervertebral disc that has undergone a nucleotomy, the envelopedefining a plurality of chambers, the chambers being configured so that,when at least certain of the chambers contain a filler material, theenvelope conforms substantially to the volume of the disc; a fillermaterial receivable in the at least certain of the chambers; and atleast one of the chambers having a filler mechanism associated with it.

One advantage of certain disclosed methods and equipments are that theyfacilitate minimally invasive formation of tissue prosthesis in situ.Another advantage of certain disclosed methods and equipments are thatthey facilitate percutaneous formation of tissue prosthesis in situ. Inaddition tissue prosthesis is provided which are resistant todelamination. In particular, in the case where the tissue prosthesis hasan envelope and filler material of the same class of material, asubstantially unified, integrated structure may be provided which isresistant to delamination and relative movement between the envelope andthe filler material. The unified structure and the fact that theenvelope is elastically deformed and is retained under tension alsorenders the envelope resistant to creasing increasing the operationalefficiency of the prosthesis by being better able to distribute forcesto the annulus fibrosis of the disc.

In addition, the use of a silicone rubber envelope in certainembodiments is particularly advantageous due to the fact that, when anucleotomy has been performed, residue remains behind which is irregularin shape. It is beneficial to have a prosthesis which expands andconforms as closely as possible to the shape (micro and macrostructure)of the cavity in order that compressive, tensile, bending and torsionalforces can be accommodated by the disc. In addition, the provision of atissue prosthesis expanding and closely conforming to the shape of thecavity results in an improvement in stimulation and deformation of theend plates of the vertebrae and thereby aiding in restoration of thenatural pumping action which assists in the influx of nutrients and theefflux of waste products from within the disc.

It is yet a further advantage of certain embodiments that the tissueprosthesis can be formed in situ in a minimally invasive manner. Theneed for invasive surgical procedures is therefore obviated and there isthe added advantage of more rapid post-operative recovery and thereduced need for a prolonged period in hospital.

In certain embodiments, the equipment further provides an efficient,easy to use manner of forming the tissue prosthesis. By having the tubesetc nested, a clinician is more easily able to manipulate the equipmentto place and form the tissue prosthesis. With the added use of a workingcannula, the access to the disc and hence the nucleus pulposus need onlyto be established once. All the remaining tubular apparatus forpositioning and forming the tissue prosthesis are slideably receivablewithin the protected confines of the working cannula. Therefore, thereis no repeated movement of having to go in and out of the tissue whichcould increase the risk of damage to muscle, subcutaneous tissue andparticularly nerves. Further, the use of a barrelled dispensing deviceconnected to a static mixer and tube which delivers the mixedbiomaterial directly into the envelope avoids the use of complex systems(for example, ones with pressure feedback etc) for injecting thematerial which may be used to overcome the changes in pressures whileinjecting into confined tissue spaces.

It is yet a further advantage that the procedure is not restricted tolarge hospitals requiring costly operating tools in the hand ofprofessionals like spinal surgeons, neurosurgeons and orthopaedicsurgeons: but can be performed by numerous physician including painphysicians, radiologists, anaesthesiologists, sports physicians and anyother professional confident of using a fluoroscope imaging device andplacing needles into intervertebral discs. The larger community andsocietal benefit of such superiority of the present inventions are greatas it improves access and affordability to a large population of chronicback pain sufferers. Other advantages include a non heat generatingcatalytic interaction (or in certain embodiments, the reaction may beslightly endothermic or slightly exothermic) for polymerisation of theflowable material, obviating the risk of thermal damage to adjacenttissues. More advantages include, prevention of leakage of flowablematerial into undesirable confines in the event the prepared tissueswalls have fissures and or breaches that communicate to areas wherethere may be organs at risk.

While the inventions described herein are described with reference tocertain exemplary embodiments related to intervertebral disc nucleusreplacement, it will readily be appreciated by persons of ordinary skillin the art, in view of this disclosure, that the inventions disclosedherein are not limited to such embodiments and that the inventionsdescribed herein are more generally related to tissue prostheses.

In certain exemplary embodiments, the filler material may be anynatural, synthetic or biological polymer. The materials may be polymersor copolymers. The material should preferably present with biocompatiblecharacteristics. The material may at least closely mimic and or at leastclosely restore the function of the joint or tissue it is replacing. Inthe case of the intervertebral disc, the material may restore thebiomechanics of the joint by restoring the intradiscal pressure andhence the hoop stresses to the annulus fibrosis. Should it be required,the material may also be able to supply sufficient pressure to the discto restore any loss in disc height or at least maintain the disc height.The material may also have some load bearing capabilities. Patientsundergoing nucleus prosthesis treatment may have a mildly compromisedannulus fibrosis (small tears and or fissures), hence the prosthesis maybear some of the axial load, whilst still sharing and distributing someof the incident load to the annulus to keep it in tension (i.e., be bothload bearing and load sharing). Also, the material should preferably notinhibit the flow of nutrients and other such fluids through the disc, asthe residual (remaining) nucleus and annulus still requires hydrationand nutrients to at least slow down or halt the degeneration of thedisc. The material may also possess resilience, viscoelasticity andfatigue resistance (as the disc is loaded cyclically during everydayactivities, the disc needs to be able to retain or at least restore itsheight under cyclic fatigue). The class of materials which suits thesefeatures are elastomers, in particular silicones. Silicones have anestablished history of use. They are extremely stable (mechanically andbiologically) in its cured form and even when they are cured in situ,the catalysts used to cure the material are not harmful to thesurrounding tissue and the curing process is harmless to the surroundingtissue. Silicones are resilient, elastic and have excellent shockabsorbing capabilities.

Although the range of hardness for the silicones (or elastomer ingeneral) which are suitable for this application are between about 5-90A (e.g., 5-15 A, 20, 20-40 A, 40-60 A, 50-70 A, 70-90 A, etc.), thepreferred hardness range is about 20-40 A and more specifically about 30A (e.g., about 27, 28, 29, 30, 31, 32, 33, etc.). Since silicones deformelastically under a given load, it spreads the load evenly across theendplates and minimizes stress concentration and or stress shieldingwhich could all lead to subsidence of the implant into the endplate.

Additionally, the filler material may have varying degrees of porosity(such as silicone foams). Porosity may allow for tissue to grow into it,it may not affect the flow of nutrients across the disc, and byadjusting the porosity, the mechanical characteristics of the materialmay also be varied (such as deformation under load, creep, fatigueproperties etc.).

The filler material may be selected to at least partially mimic naturalbiomechanical characteristics of the nucleus pulposus of the disc.

The at least one envelope may be made from an elastomeric material,preferably a silicone, which is biologically inert and which canelastically deform up to 3, 5, 7, 10, 30, 50, 80, 100, 120, or 150 timesthe size of the at least one envelope in its relaxed state. In someembodiments, the at least one envelope may be made from the siliconerubber material which is substantially biologically inert and which canelastically deform in the ranges of 3 to 5, 5 to 7, 7 to 10, 10 to 50,10 to 100, 20 to 150, 30 to 100, 20 to 120, 70 to 100, or 50 to 150times the size of the at least one envelope in its relaxed state. Inother embodiments, the envelope may be compliant (e.g., with or withoutbe elastic) which may allow the envelope to conform or substantiallyconform to the cavity.

The at least one envelope may also be made of other materials. Forexample, the at least one envelope made from less expansible materialsuch as a biological or a synthetic polymeric material. A suitablesynthetic polymeric material may, for example, be polyester such aspolyethylene terephthalate (PET). The at least one envelope may also beconstructed of a knitted PET material so that, when the filler materialis charged into the at least one envelope, the filler material fillsforamens or interstices in the at least one envelope to form anintegrated structure which resists relative movement between the fillermaterial and the at least one envelope. Alternatively, the knitted PETmaterial may be coated with silicone allowing the filler material tointegrate with the coating.

The materials which the envelope may be made from may be any natural,synthetic or biological polymer or copolymer which possessesbiocompatibility. The envelope may be a porous material which allows forthe surrounding tissue to grow into the implant and anchor or stabilizethe implant within the disc space (or in general at the tissue sitewhich it is being implanted into). The porosity may also allow for thefiller material to seep through the envelope and bond to the envelope toform a substantially unified structure. Should the envelope be made of anon porous material, the advantage is that it prevents filler materialfrom seeping into unwanted fissures, cracks and tears in the annulus.Even if the envelope is non porous, having filler and envelope of thesame class of materials can also achieve the same substantialunification. Having a unified structure means that there is no relativemovement between the filler and envelope, thus reducing the wear andhence the wear particles being produced. An advantage of having anenvelope of an elastic, resilient material such as silicone is that theenvelope may be capable of expanding and conforming to the macro andmicro structures of the interior of the disc. This also increases thecontact area of the implant across the endplates reducing stressconcentrations and thus reducing the chances of implant subsidence.

As used in the specification the performance of a nucleotomy on the discinvolves the removal of a certain amount of the nuclear tissueconstituting the nucleus pulposus. The methods, devices, and/or systemsdisclosed herein often refer to the removal of the nuclear tissue. Theamount of nuclear material removed may vary from procedure to procedureand this will be understood by those skilled in the art in view of thepresent disclosure. Using the devices, methods, and/or systems disclosedherein, it may be desirable to completely remove the nuclear tissue, inother instances it may be sufficient to substantially remove the nucleartissue, or in other instances it may be sufficient to partially removethe nuclear tissue.

Depending on the degree of nucleus pulposus removal, the prosthesis maybe classed as a total nucleus replacement or a partial nucleusreplacement. Regardless of the degree of tissue removal, the one or moreimplants may completely or at least partially fill the cavity whichremains. Completely filling the cavity will allow the transfer of loadonto the annulus and restore the hoop stresses which are necessary tominimise the shear stresses on the annular layers and hence, at leastslow further degeneration of the disc. If the implant were to partiallyfill the space, it allows the implant to reposition itself in a mannerwhich prevents further migration and minimise the chances of extrusion.It may also reposition itself to a position which is of least resistanceand hence minimise the stresses on the implant and surrounding tissue.The kangaroo data detailed later demonstrates the restoration of thekinematics of the spine even after the partial filling of the nucleuscavity.

One of the advantages of the implant is that multiple units can beimplanted from various directions to achieve a partial, near complete orcomplete filling of the nuclear space. For example one device can beimplanted on the right side from the right posterolateral corner or theright lateral corner or anteriorly. The other one can be implanted fromthe opposite side as well.

In certain embodiments, a percutaneous approach as opposed to open orminimally invasive surgery may be used. With a percutaneous approach, aneedle is usually used for intravenous injections, intramuscularinjections or intradiscal injections. For minimally invasive surgery,some operations have been described and defined as requiring 1.visualisation: which may be magnified by using optical loops, endoscopiccameras, microscopes etc. 2. illumination which is obtained either viacold light sources, optical cables or other means 3. retraction;retraction of tissues is an important components of minimally invasivesurgery as a lot of resources and effort have gone into developing thisthird and final component of minimally invasive surgery. It isunderstandable that a small incision may be required for minimallyinvasive surgery (e.g., about 5 cm, about 6 cm, about 7 cm, etc.) andsuch incisions can be multiple in nature. The present inventors proposethe percutaneous surgery which is carried out without the aid of opticalvisualisation, illumination, or the use of any specialised retractors asis required for minimally invasive surgery. In certain embodiments themethod may be performed as a micro-invasive surgery. For example, incertain embodiments, the opening used may be less than 4 cm. Forexample, the opening (e.g., the incision, puncture, or other means ofaccessing the body) may be up to 200 microns, or up to 400 microns, orup to 800 microns (e.g. about 200, 250, 300, 350, 400, 450, 500, 550,600, 650, 700, 750, or 800) or alternatively of the order of about 2 cmto about 4 cm (e.g., about 2, 2.5, 3, 3.5, 4) or alternatively, of theorder of up to 1 cm or up to 6 cm.

The methods and apparatus' defined for formation and insertion of tissueprosthesis can be used in many clinical scenarios in varying fashions.In the area of degenerative disc of the spine, advanced stage discdiseases requires the application of posterior spinal fusion with orwithout decompression with the fusion either being static or dynamic. Insituations where the fusion is dynamic and performed with the use ofpedicle screws there is a risk that the lordosis of the motion segmentmay be compromised. In static fusions, the lordosis is recreated by useof a interbody cage or interbody fusion device and the operation iscalled posterior interbody lumbar fusion. In dynamic fusions, the CPDRDcan be implanted in an interbody manner within the nucleus to recreatethe hunbar lordosis, to share load bearing anteriorly and therebyprevent loosening of the pedicle screws. This method may be a preferablemethod of performing posterior dynamic fusion of the spine, usingexisting systems like Dynesis, N-Flexrod (Spine next).

Further, in more advanced disc disease, the clinical condition of spinalstenosis exists where the gap between the spinous processes decreases.In these patients, the classical older operation has been laminectomy,foraminolaminectomy, posterior spinal decompression. More modernoperations include implantation of the Wallis device. X-Stop, or InSpace, Diam. However, these interspinous distraction devices havenumerous disadvantages including incisions to expose the area (minimallyinvasive spinal surgery), and/or being hard and not allowing for shockabsorption. The device disclosed herein can be implanted in theinterspinous area in a percutaneous manner after clearing theinterspinous area with the patient in a flexed position. The distractionof the interspinous area leads to effective improvement in the spinalstenosis. The same interspinous implant can be used after discectomiesperformed for herniated nucleus pulposus fragments either by smallincision or endoscopically.

In certain embodiments, an apparatus for forming a tissue prosthesis(e.g. a disk prosthesis) in situ in a patient's body may be provided.The apparatus may comprise, an inflatable component and a deliverymechanism for delivering a filler material into the inflatable componentso that when the filler material is cured, a unified prosthesis isformed. In certain embodiments, the delivery mechanism may comprise atleast one priming mechanism (e.g., a hole, valve, or opening) proximateto the area where the inflatable component is coupled to the deliverymechanism (see, for example. FIG. 38B for an example of a hole 1010 oneither side of the delivery mechanism and proximate to an end of thedelivery mechanism). The at least one hole may be large enough for gasto pass through but small enough so that the filler material can notpass through. In this manner, it may be possible to prime the apparatusto remove a substantial amount of the gas from within the system so thatthe gas does not need to be purged when the delivery system is in thebody.

Certain embodiments may provide a method system or apparatus thatcomprises any of the details disclosed throughout this specificationexclusive of for example, a bone grafting, stabilization, or fasteningand/or holding devices such as screws (e.g., facet screws, and/orpedicle screws), staples, etc. For example, in certain embodiments, amethod may be provided that consists only of accessing the site in thebody of a patient (e.g., a vertebral disk), removing tissue from thesite to form a cavity, if necessary, inserting an inflatable componentinto the cavity, and delivering, via a delivery mechanism, a fillermaterial into the inflatable component so that when the filler materialis cured, a unified prosthesis is formed. The exemplary method mayoptionally include some of the additional steps disclosed throughout thespecification. In certain embodiments, a method for completing theimplantation of a tissue prosthesis in situ in a patient's body may beprovided and the method may consist exclusively of accessing the site inthe body of a patient; optionally, removing tissue from the site to forma cavity; optionally, priming a delivery mechanism with filler materialto remove gas from within the delivery system; optionally, sizing thecavity; inserting an inflatable component into the cavity; delivering afiller material into the inflatable component so that when the fillermaterial is cured, a unified prosthesis is formed; and completing theprocedure by removing the delivery mechanism from the site in thepatients body and optionally, applying a bandage to the site. In certainembodiments, the method may not require a bandage but may merely becompleted without the use of any mechanical closing means such as forexample, sutchers or stitches.

Certain embodiments may provide a method for forming a tissue prosthesisin situ in a patient's body. The method may comprise accessing the sitein the body of a patient (e.g., a vertebral disk), removing tissue fromthe site to form a cavity, if necessary, and priming a deliverymechanism with filler material to remove gas from within the deliverysystem. The method may further comprise inserting an inflatablecomponent into the cavity, and delivering, via a delivery mechanism, afiller material into the inflatable component so that when the fillermaterial is cured, a unified prosthesis is formed.

In certain embodiments, the delivery mechanism may be configured to beprimed prior to forming the tissue prosthesis and the inflatablecomponent may be deflated during the priming so that after the deliverymechanism is primed, there is an acceptable amount of gas (e.g.,substantially no gas or a minimal amount of gas) in the inflatablecomponent, thereby further eliminating the need for a gas removal systemduring delivery of the filler material (e.g., a two lumen system such asdiscussed elsewhere herein). In certain embodiments, the openingdiscussed above may be used to remove the gas. In particular, as thefiller material fills the delivery mechanism, the gas within the systemmay be pushed out through the hole. In this manner, only a desirableamount of gas may remain in the delivery mechanism. In certainembodiments, the inflatable component may be at least partially primedwith filler material. Partially priming the inflatable component mayinclude partially filling the inflatable component in a manner such thatthe inflatable component remains in a relaxed state or alternatively ina state where it may still be inserted into the site of the body withoutsubstantially more difficulty than if the inflatable component was notprimed (e.g., readily inserted into the working cannula after priming).

In certain embodiments, delivery mechanism and inflatable component mayform a closed system or in certain embodiments, the delivery mechanismand inflatable component may form an open system. An open system is onewhere matter and or energy can flow into and or out of the system. Asystem that receives inputs of energy and or matter and then outputsmaterial into surrounding environments is termed an open system. Incontrast, a closed system is where energy can enter or leave but mattermay not. A system that is shut off from the surrounding environment andis self contained is termed a closed system. More specifically, a closedsystem may be enclosed by barriers which prevent the influx of materialand also efflux of material. The volume, pressure and or temperature arestill able to change, but, fluid and or other matter are not in directfluid communication with the surrounds external to the bounds of theclosed system.

In certain embodiments, the site within the body of the patient may beaccessed in a minimally invasive manner, percutaneously, or in amicro-invasive manner. Additionally, the diameter of the access pointfor accessing the site within the patient's body may less than 6 cm,less than 5 cm, less than 4 cm or less than 3 cm, less than 2 cm lessthan 1 cm, less than 0.75 cm, less than 0.6 cm, less than 0.5 cm, orless than 0.4 cm. In certain embodiments, the access point through theskin for accessing the site within the patient's body may besufficiently small so as not to require anything more than a bandage. Incertain embodiments, the access point may be sufficiently small so asnot to require any closing device such as for example, stitches,sutures, or a fastening bandage upon termination of the surgicalprocedure.

In certain embodiments, the filler material may have a shore hardness ofless than about 10 A, between 10 to 20 A, between 20 to 30 A, between 30to 50 A, between 50 to 70 A or greater than 70 A, but preferably about30 A. In certain embodiments the filler material may be CSM-2186-14,manufactured by Nusil Technologies or MED5-4230, manufactured by NusilTeclhnologies. In certain embodiments, the inflatable component may bemade from liquid silicone rubbers. Examples include, but are not limitedto, MED-4805, MED-4810, MED-4820, MED-4830, MED-4840 manufactured byNusil Technologies. In certain embodiments, the inflatable component maybe made from high consistency elastomers. Examples include, but are notlimited to MED-2174, MED4-4515, MED-4520, MED-4535 manufactured by NusilTechnologies. In certain embodiments, the inflatable component may bemade from dispersions. Examples include, but are not limited toMED-2214, MED-6400, MED-6600, MED1-6604, MED-6605 manufactured by NusilTechnologies.

Certain embodiments may provide a tissue prosthesis comprising: aninflatable component; and a filler material received in a fluent statein the inflatable component, the filler material being of an elastomericmaterial with a shore hardness of less than 90 A and preferably about 30A. In certain embodiments the filler material may be CSM-2186-14,manufactured by Nusil Technologies or MED5-4230, manufactured by NusilTechnologies. In certain embodiments, the inflatable component may beMED-4830, manufactured by Nusil Technologies.

The filler material is a two-part pourable silicone elastomer that curesat room temperature. It contains about 5% BaSO₄ (e.g., about 3%, 4%, 5%,6%, or 7%) in both parts and mixes at about a ratio of 3:1 to 1:3 (e.g.0.5:1 to 1.5:1, 1:1). The viscosity of part A may be about 105,000 cP(e.g., about 100,000 cp, 101.000 cp, 102.000 cp, 103,000 cp, 104,000 cp,105.000 cp, 106,000 cp, 107,000 cp, 108,000 cp, 109,000 cp, or 110,000cp) while the viscosity of part B may be about 71,000 cp (e.g., about65,000 cp, 67,000 cp, 69,000 cp, 71,000 cp, 73000 cp, or 75,000 cp).Additionally, the filler material may have a durometer of about 22-35D2240 (e.g., about 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 or34), a tensile strength of between 850 to 1200 psi (e.g., about 900 psi,950 psi, 1000 psi, 1050 psi, or 1100 psi), an elongation of between500%-1200% (e.g., about 500%, 550%, 600%, 650%, 700%, 750%, 800%, 850%,900,% or 1000%), and a tear strength of between 80-120 (e.g., about 90ppi, 95 ppi, 100 ppi, 105 ppi, or 110 ppi). The filler material maytypically be filled with inorganic material for example silica, titaniumdioxide, fly ash or other bio-acceptable fillers (e.g. amorphoussilica). These fillers can optionally be surface treated withhydrophilic agents and/or hydrophobic agents. The inorganic fillmaterial may be present in the filler material in amounts between 5 and50 wt. %, (e.g., 10-40 wt. % including 15 wt. %, 20 wt. % up to 30 wt.%, 35 wt. %, 40 wt. %). The inorganic fill material may be present ineither part A or B or both A and B.

The envelope material may typically be a two-part translucent siliconesystem that cures rapidly with no required post-cure. It mixes at abouta 3:1 to 1:3 ratio (e.g., 0.5:1 to 1.5:1 and 1:1). The composition mayhave a durometer of about 25-35 D2240 (e.g., about 26, 27, 28, 29, 30,31, 32, 33, or 34), a tensile strength of between 1100 and 1500 psi(e.g., about 1250 psi, 1300 psi, 1350 psi, 1400 psi, or 1450 psi), anelongation of between 500% and 1100% (e.g., about 550% 600%, 650%, 700%,750%, 800%, 8505, 900%, 950% or 1000%), a tear strength of between 140175 ppi (e.g., about 140 ppi, 145 ppi, 150 ppi, 155 ppi, or 160 ppi),and a stress at 200% strain of between 150 and 200 psi (e.g., about 160psi, 165 psi, 170 psi, 175 psi, 180 psi, 185 psi, or 190 psi).

The silicone used for the filler material or envelope material mayinclude any one of a variety of silicones generally referred tobio-compatible elastomers formed from polysiloxanes orpolyorganosiloxanes which are polymers having the general chemicalformula [R₂SiO]_(n), where R is any suitable organic group and n is anyinteger. Such polysiloxanes suitable for these purposes may also includea broad family of more complex synthetic polymers containing a repeatingsilicon-oxygen backbone with organic side groups attached viacarbon-silicon bonds. Such complex silicones, or polymeric siloxanes,may be linear, branched or cross-linked, and can be represented by theformula [R_(p) SiO_((4−p/2))]_(m), where p is 1-3, m>1, and R is anysuitable organic group such as alkyl, alkenyl, fluoroalkyl, phenyl,vinyl, hydroxyl, alkoxy, amino or alkylamino or combination of one ormore of these organic groups, e.g., -phenylvinyl. The term silicone asused herein is also meant to include elastomers that are hetero- orcopolymers of the above-described polysiloxanes. The polysiloxanessuitable for the present invention may also have their terminal endssuch as alkyl, alkenyl, fluoroalkyl, phenyl, hydride, vinyl, hydroxyl,alkoxy, amino or alkylamino group or combinations of one or more ofthese organic groups, e.g., -alkylvinyl (this could be part A of atwo-part system). The polysiloxanes suitable for example as a counterpart polysiloxane (e.g., part B) can be modified to include functional,active or inactive organic groups for various purposes, such as topromote crosslinking (for example hydrides or other terminal groupsfunctional groups suitable for treating with ethylenically unsaturatedfunctional groups) or for copolymerization or other reactions. The twogroups undergoing an addition reaction during curing. Such additionreaction can be aided by a Group VIII metal (e.g., platinum, rhodium, orpalladium).

Non-limiting examples of some polysiloxanes include:polydiorganosiloxanes, polyaklysiloxanes, polydialkylsiloxanes,polydimethylsiloxanes, polyaminoalyklisiloxanes, polyaminoalklsiloxanes,polyethyleneglycol-polydimethyl siloxane co-polymers, siliconepolyesters, polysiloxane-polylactone copolymers,polydimethyldiphenylsiloxane, polyalkylsiloxane-polyurethane copolymerswith one or more terminal groups such as alkyl, alkenyl, fluoroalkyl,phenyl, vinyl hydroxyl, alkoxy, amino or alkylamino group or combinationof two, three or more of these groups (e.g., -alkylvinyl).

In certain embodiments, the priming may occur after the inflatablecomponent is inserted into the cavity. In either of these cases, thepriming may be achieved by having a small opening or several smallperforations at some point near the distal end of the deliverymechanism, preferably just proximal to the inflatable member. Thisopening may allow for gases or certain fluids within the deliverymechanism to escape through the opening, but will substantially limitthe flow of the filler material through this opening. The opening mayallow less viscous fluids to pass through the opening easily, butsubstantially limit more viscous fluids from passing through thisopening. Therefore, as the filler material primes the deliverymechanism, the gases or certain fluids within the delivery mechanism maybe pushed out through this opening and limit the entrapment of gas orcertain fluids within the inflatable member. The opening may be a slitor a hole (see, for example. FIG. 95 for an example of a slit 1008 on aside of the delivery mechanism and proximate to an end of the deliverymechanism). In the case of a slit, the width of the slit may be lessthan 0.1 mm, between 0.1 to 0.5 mm, between 0.5 to 1 mm, between 1 to 5mm or greater than 5 mm. In the case of a hole, the diameter may be lessthan 0.1 mm, between 0.1 to 0.5 mm, between 0.5 to 1 mm, between 1 to 5mm or greater than 5 mm. In certain embodiments, the inflatablecomponent is deflated during the priming and preferably maintaineddeflated until at least the delivery mechanism is substantially primed.In either of these situations, after priming, there may be substantiallyminimal quantities of gas or certain fluids in the inflatable component,thereby eliminating the need for a gas removal system (e.g., a secondlumen) during delivery of the filler material. Additionally, in certainembodiments, the inflatable component may be primed during the priming.

In certain embodiments, the body of the patient may be accessed in aminimally invasive manner, percutaneously, or in a micro-invasivemanner. Additionally, the diameter of the incision for accessing thepatient's body may less than 6 cm, less than 5 cm, less than 3 cm orless than 2 cm. In some embodiments, the incision may be less than 1 cm.In certain embodiments, no external stitches would be required to closethe incision or puncture created when the site is accessed.

In certain embodiments, the delivery apparatus may comprise a carriertube for carrying a component of the prosthesis at its distal end. Thereis also a filler tube which is slideably receivable within the lumen ofthe carrier tube with clearance. At some point near the distal end ofthe carrier tube is at least one slit or several small perforationswhich may allow for gases or certain fluids within the deliverymechanism to escape through the opening, but will substantially limitthe flow of the filler material through this opening. The opening mayallow less viscous fluids to pass through the opening easily, butsubstantially limit more viscous fluids, such as the biomaterial, frompassing through this opening. The method of forming the implant in situmay comprise positioning the carrier tube at the desired location withinthe patient's body. Then the filler tube (which may be attached to amaterial dispenser apparatus) is primed substantially with thebiomaterial prior to being inserted into the carrier tube. As the fillertube is inserted into the carrier tube, the volume of gas, or air, orother fluids within the delivery apparatus, are displaced by the volumeoccupied by the introduction of the filler tube. This volumous gas isdisplaced through the perforations at the distal end of the carriertube. The gas within the delivery apparatus may preferably be displacedthrough the perforations at the distal end of the carrier tube than theannular space between the carrier tube and filler tube for a couple ofreasons. First, the biomaterial may have overflowed from the distal tipof the filler tube (substantially enough), to form a plug at the tip ofthe filler tube as it is introduced through the carrier tube, therebynot allowing gas to flow around and between the carrier tube and fillertube. Second, the resistance to the flow of gas or air is significantlyless through the perforations than through the annular space between thefiller tube and carrier tube.

Whatever the case may be, substantial volumes of the gas, air or certainfluids within the delivery apparatus would have been displaced and onlya small quantity of air entrapment is likely to occur within theimplant. Additionally, if the component of the implant were to bemaintained collapsed (either through a clamping mechanism, or thesheath) throughout the procedure whilst the filler tube is beingintroduced, then removal of the sheath or clamping mechanism from aroundthe component of the implant would result in an even further reductionof air entrapment into the component.

Using the apparatus described in above, a similar method may be used toform the tissue prosthesis. If the filler tube were to terminateproximally to the perforation within the carrier tube, when nested andassembled as it would be in use, the filler tube may not need to beprimed before being introduced into the lumen of the carrier tube. Ifthe resistance to the flow of gas or air at the perforations issignificantly less than that of the annular space between the carriertube and the filler tube, then as the filler material is charged throughthe filler tube, the air or gas may be displaced through theperforations, minimizing air entrapment into the envelope.

In certain embodiments, the means for maintaining the envelope collapsedmay be a sheath which has built in weaknesses in its walls at its distalend. Rather than having to retract the sheath, by delivering thebiomaterial into the envelope, causes a rise in the internal pressure,breaking the sheath open (in the form of e.g., an orange peel opening)and filling the envelope can commence with minimal introduction of airor gases into the envelope. This form of a sheath may be used to allowfor easy delivery of the envelope through the introducer (workingcannula) and rather than having to retract the sheath, any form ofpressure (such as that by inflating the envelope with air) will breakthe sheath open, thereby exposing the envelope within the disc cavity.Preferably however, the sheath will be maintained over the envelopeuntil such time the biomaterial has reached the envelope and as thepressure builds up within the envelope, the sheath breaks open and theexpansion and filling of the envelope can commence (with minimal airentrapment). This apparatus may be applicable in combination with theapparatus and method disclosed in 1 and 2 (above).

The preferred number of mixing elements for the static mixer, to achievean optimal mix and hence an optimal cure characteristics of thebiomaterial, are 12. However, the mixing elements may range up to about5, 10, 15, 20, 25, 30, 35.

Exemplary elements of percutaneous surgery is the development of aseries of nested tubes that may or may not interlock with each other byvarious means which enables the device in its preformed or fully formedstage to be delivered to the tissue site being treated to achieve animplantable status. A component of these nested tubes is a workingcannula which has the advantages of docking and can have elements whichlock the other tubes or the unlocking and unsheathing of a component ofthe prosthesis.

Advantages of the system may include: (1) that it is capable ofachieving compactness with the system and fit lots of components andelements into a small confinement; (2) the compactness of the systemprovides the means for conducting percutaneous, minimally invasiveprocedures: and the working cannula is docked relative to the patientand the tubes which go through the working cannula are locked orlockable or reversibly lockable to the working cannula. This means thatduring the implant positioning, deployment or filling process, theprocedure can be performed in a stable manner and there is nounnecessary or unintentional relative movement during the implantationwhich can damage the tissue and the tissue prosthesis. Additionally,this may help avoid repeated trauma to tissue as instruments go in andout—preventing the crowding of muscles into the path and isolatingstructures like nerves etc—thereby not only protects outerstructures—but internally protects our device. It may also maintain thedeployment of a disc device or prosthesis) in the desired position.Additionally, in certain embodiments, the device and or components ofthe device may be substantially frictionless. If more force is requiredratchets can be built into the wall to crawl the progress of the deviceand or components of the device and or components of the system.

Implant detachment means may include, screw in and screw off of theimplant, chemically dissolve the interface which holds the implant,vibrational detachment, RF (Radio-frequency) or infrared cutter. Othermeans of implant removal include, sliding the implant off the carriertube by utilization of slideably displaceable nested tubes. These can betubular structures. Also, external or internal cutting mechanism on thetubes which can sever the implant from the delivery apparatus. Also,means of twisting and or crimping the neck of the implant. This can bothseal and detach the implant. Also if the means in which the envelope isheld onto the carrier tube is purely an interference fit or frictionfit, or just tight fit, then pulling on the carrier tube can result indetachment of the envelope. Also, the tube can be rotated to detach.Also, another means for detachment of the implant can includelubrication of the interface which holds the implant. There may be apreformed opening or multiple preformed perforations at the distal endof the carrier tube and or filler tube. The perforations on the carriertube may be at or near the implant interface. Once the implant has beensubstantially filled to capacity, the pressure of filling forces thefiller material to seep through these perforations and lubricate theinterface of the implant allowing it to be removed easily. Othersuitable, biocompatible lubricating media may be used in this way orsimilar way to lubricate the interface which holds the implant.

In certain embodiments, a pressure generating apparatus may preventouter bulging of the barrels, counterbalances the thrust force.Alternatively, the barrel may be integrated into the base of thepressure generating apparatus.

Referring to FIG. 1, an intervertebral disc 10 is generally arrangedbetween adjacent vertebrae 12 and 14. The disc 10 comprises an annulusfibrosis 16 made up of concentric layers of fibrous tissue. The annulusfibrosis 16 circumscribes a nucleus pulposus 18 of the disc 10, thenucleus pulposus 18 being of soft tissue. The disc 10 is sandwichedbetween end plates 20 of the vertebrae 12 and 14. Relative movementbetween the vertebrae 12 and 14 causes compression of the nucleuspulposus 18 by the end plates 20. This serves to assist in the influx ofnutrients into the disc 10 and the efflux of waste products from withinthe disc 10.

Certain exemplary embodiments disclosed herein provide methods forimplanting an intervertebral disc implant into an intervertebral disk bypercutaneously performing a nucleotomy on the disc, if necessary, toremove a nucleus pulposus of the disc to create a volume. Once thevolume is created, at least one envelope of the implant is inserted intothe volume and an interior of the envelope is charged with at least onefiller material in a manner to allow the at least one envelope to expandto conform substantially, or partially to the volume. Additionally, theinterior of the at least one envelope is closed oft or substantiallyclose off, to retain the at least one filler material within theenvelope. As discussed herein, the filler material may be selected to atleast partially mimic natural biomechanical characteristics of thenucleus pulposus of the disc.

As will be discussed in more detail elsewhere herein, the methods mayfurther include inserting the envelope into the volume using anintroducer by placing the envelope in a collapsed state on a distal endof the introducer and inserted percutaneously through an opening in anannulus of the disc. Further, the opening may be the same opening viawhich the nucleotomy had been performed. The methods may also includecharging the filler material into the interior of the envelope throughthe introducer. Further, the methods may include closing off theinterior of the envelope by sealing a wall of the envelope. In certainexemplary embodiments, the methods may include closing off the interiorof the envelope by the action of withdrawing the introducer from theenvelope. In certain embodiments, the methods may use a minimallyinvasive technique or the percutaneously technique may be combined withthe minimally invasive technique.

In certain exemplary embodiments the methods for implanting anintervertebral disc implant into an intervertebral disc may includepercutaneously performing a nucleotomy on the disc to remove a nucleuspulposus of the disc to create a volume; inserting an introducer into anopening formed in an annulus of the disc; and introducing into thevolume, via the introducer, at least one element which changes from afirst configuration, in which the at least one element is able to beinserted into the introducer, to a second configuration in which the atleast one element conforms substantially to the volume.

The methods may further include using a single element which, in itssecond configuration, conforms substantially or at least partially tothe volume of the disc. Alternatively, the methods may include using aplurality of elements which together, when each such element is in itssecond configuration, conform substantially or at least partially to thevolume of the disc. In the latter case, the methods may include, priorto insertion of the elements in the volume, introducing at least oneenvelope, in a collapsed state, into the volume and introducing theelements into the at least one envelope to cause the at least oneenvelope to expand to conform substantially or sufficiently to thevolume of the disc. The methods may include, after introduction of theelements into the at least one envelope, closing off a filler opening ofthe at least one envelope. Preferably, the methods includes closing offthe filler opening of the at least one envelope by withdrawal of theintroducer from the filler opening of the envelope.

In certain exemplary embodiments, there is provided an introducer forintroducing an intervertebral disc implant into a disc that hasundergone a nucleotomy, the introducer including at least two sleevesarranged telescopically with respect to each other; and a displacementmechanism arranged on an operatively inner surface of an innermost oneof the sleeves for assisting in displacing filler material along thesleeves into an interior of the disc, in use.

The displacement mechanism may comprise a ratchet arrangement for urgingthe filler material along the sleeve.

In certain exemplary embodiments, there may be provided methods ofpreparing a first assembly of a tissue prosthesis system for insertioninto a patient's body, the method, or methods, comprising providing thefirst assembly which comprises a plurality of nested, or partiallynested, tubes, one of the tubes being a carrier tube: mounting acomponent of the prosthesis on a distal end of the carrier tube, thecomponent being of an elastically deformable material or a sufficientlyelastically deformable material, inserting a stiffening member into thefirst assembly so that the stiffening member extends into an interior ofthe component and causing a proximal end of the stiffening member tosealingly engage a proximal end of the first assembly; attaching awithdrawing device to the first assembly so that the withdrawing deviceis in fluid communication with at least the interior of the component;and operating the withdrawing device to reduce the pressure in theinterior of the component to cause the component to collapse about thestiffening member. The stiffening member may allow the retraction of theouter sleeve, which covers the component of the prosthesis, without thecomponent buckling or prevent the total retraction into the carrier tubewhen the syringe is withdrawn to collapse the component.

The method, or methods, may include attaching the withdrawing device toa fluid port of the first assembly in a sealing manner. The withdrawingdevice may be a syringe which is attached by a Luer lock mechanism tothe fluid port of the first assembly. Other withdrawing devices may be avacuum pump, a pre-evacuated container (such as vacutainer), or acontainer with a preformed low pressure environment, or any apparatus(e.g., which has moveable walls allowing for the volume of the system tobe alterable).

After the component has been collapsed, or sufficiently collapsed, aboutthe stiffening member, the method, or methods, may include placing aprotective sheath about the component. The method, or methods, mayinclude placing the protective sheath about the component by sliding theprotective sheath over the component, the protective sheath constitutingone of the tubes of the nested tubes of the first assembly.

Further, the method, or methods, may include treating one of theprotective sheath and the component with a lubricating medium tofacilitate relative displacement between the protective sheath and thecomponent.

Exemplary lubricants may include, but not limited to, media such aswater for injections, 0.9% salines solution, albumin, fat, mineral oil,lipids, silicone oils, etc.

The method, or methods, may include using the withdrawing device to testthe integrity of the combination of the first assembly and the componentand the stiffening member attached to the first assembly. Testing theintegrity may include determining whether the interior of the envelopeis in fluid communication with fluid external to the walls of theenvelope, and/or inspecting whether the system still remains a closedsystem or substantially closed system, or whether it is an open system.The feedback mechanism may have an associated pressure, force or volumemonitor which is capable of indicating whether or not there is a breachof the seal. These monitors may indicate whether there is a loss inpressure, force, volume associated with the applied pressure, force orvolume.

In certain exemplary embodiments, there may be provided methods offorming a tissue prosthesis at a site in a patient's body, the methodsmay comprise providing a first assembly comprising a plurality of nestedtubes, one of the tubes being a carrier tube with a component of theprosthesis carried at a distal end of the carrier tube; inserting thefirst assembly into a cannula placed in the patient's body; magneticallyattaching or engaging a second assembly to a proximal end of the firstassembly: and charging a filler material from the second assembly intothe component and allowing the filler material to set.

The methods may include, initially, preparing the first assembly asdescribed elsewhere herein.

The methods may include, once the distal end of the first assembly is atthe desired location at the site in the patient's body, withdrawing theprotective sheath to expose the component, the component being anenvelope of an elastically deformable material. The methods may alsoinclude activating the withdrawing device as the sheath is withdrawn tosubstantially collapse the envelope, minimising the contact area betweenthe envelope and the sheath, minimise the friction between the envelopeand the sheath and hence facilitate sliding between the envelope and thesheath.

The methods may include removing a stiffening rod prior to magneticallyattaching the second assembly to the first assembly. Further, themethods may include causing the second assembly to engage sealingly withthe first assembly so that, together with the component and thewithdrawing device, a closed system is formed.

After the second assembly has been attached to the first assembly, themethods may include operating the withdrawing device to create a lowpressure in the component. Further, the methods may include using thewithdrawing device to test the integrity of the system comprising thetwo assemblies and the component attached to the first assembly. Thismay be performed by either withdrawing or pushing forward on the pistonof the withdrawing device and it should also be noted that the integrityof the system can be tested at the stage once the first assembly hasbeen introduced to the desired location in the patients body (asdescribed above)

The methods may include dispensing the filler material from a dispenserof the second assembly. The methods may also include purging fillermaterial from the dispenser prior to attaching the dispenser to a staticmixer constituting a part of the second assembly. The methods mayinclude, during filling of the component via a filler tube extendingfrom the static mixer, operating the withdrawing device at least tomaintain, or increase, the volume of the closed system. Mixing may alsobe performed dynamically. Also, the parts may be premixed and deliveredrather than being mixed during the delivery (or charging) process. Incertain aspects, the mixing may not be necessary if it is a single partfiller material. The filler material may be a single part, or at least a2 part mixture (i.e., may have 3 parts, etc.). For example, the 3^(rd)component of the mixture may be the initiating catalyst. Alternatively,these initiators for the curing reaction may be coated onto the innersurfaces of the lumen which the material comes into contact. Forexample, the lining of the static mixer, mixing elements, and the lumenof the filler tube may be treated with a platinum catalyst. Certainprimers may contain the catalyst. Therefore the inner lining of theenvelope may be coated/treated with the primer and when the 2 partfiller material enters and fills the envelope, it comes into contactwith the inner lining of the envelope, thereby initiating oraccelerating the cure. Additionally, because it is also a primer, it mayenhance the adhesion between the envelope and the filler material.

The methods may include, after filling the component, detaching thecarrier tube from the tissue prosthesis formed by the combination of thecomponent and the filler material contained in the component. Thecarrier tube may be detached prior to the filler material having curedor set or after the filler material has at least partially set. In someaspects, the carrier tube may be detached prior to the filler materialhaving been partially or substantially cured. The methods may includedetaching the carrier tube from the tissue prosthesis when the requiredpressure has been reached in the component. In the case ofintervertebral disc nucleus prosthesis, the required pressure may bethat which restores the height of the disc to that of pre-surgery, orthat which substantially fills the volume of the disc. However incertain embodiments, pressure may not be a determinant. Another methodmay include the filling of the component being determined by the volume.The volume to be replaced can be determined by visual or mathematicalcalculation of the nuclear area from patients own images, amount ofnuclear material removed, use of a sizing tool, progressive surgeonexperience, use of a software or self learning algorithm that maydetermine the volume of nucleus that either exists or is removed or maybe required to be replaced. The method of determining the nuclear volumecould also use a disc mapping strategy. Additional methods may includethe methods described in International Application No. PCT/AU03/001289,filed on Sep. 30, 2003 entitled “Mapping and Viewing Device for anIntervertebral Disc”, which claimed priority from Australian ProvisionalApplication No. 2002951762 filed on Oct. 1, 2002. The entire contents ofwhich are herein incorporated by reference in its entirety

In certain exemplary embodiments, the methods may include detaching thetissue prosthesis by relative axial motion between the carrier tube anda displacement device of the first assembly. The displacement device maybe a further tube arranged about the carrier tube and the relative axialmotion may be affected by withdrawing the carrier tube relative to thedisplacement device. In certain exemplary embodiments, the methods mayinclude detaching the tissue prosthesis by filling the component withfiller material to the extent that the component is released from thecarrier tube. In a further exemplary embodiment, the methods may includedetaching the tissue prosthesis by manipulating the carrier tuberelative to the component to cause separation of a part of the componentattached to the carrier tube from a remainder of the component, theseparation occurring at a zone of weakness in the component. Themanipulation may involve rotating the carrier tube with respect to thecomponent.

The methods may further include, after formation of the tissueprosthesis, tamping a part of the tissue prosthesis into position.

In certain exemplary embodiments, the methods may also include, beforeplacing the component in position at the site, preparing the site. Themethods may include preparing the site by removing degenerative tissuefrom the site prior to placing the component at the site.

In certain exemplary embodiments, there may be provided methods offorming a tissue prosthesis in situ at a site in a patient's body, themethods may comprise accessing the site in the patient's body; ifnecessary, removing tissue from the site to form a cavity; inserting atleast one envelope of a biologically inert, elastically deformablematerial into the cavity; charging a filler material, in a fluent state,into the envelope to cause the envelope to expand and conform to theshape of the cavity; and allowing the filler material to cure, thefiller material being of the same class of material as the envelope sothat, when the filler material has cured, a unified, or substantiallyunified, prosthesis is formed.

The methods may further include accessing the site by inserting anintroducer through an aperture formed in tissue associated with the siteand removing nuclear tissue, if required, from the site. The nuclearmaterial may be removed by mechanical, ultrasonic, laser, Argon gas orradio frequency ablation, or the like, in combination with suction andirrigation. For example, mechanical removal may be effected by using areaming-type tool. Additional methods may include the methods describedin U.S. Provisional Application No. 60/971,633, filed on Sep. 12, 2007,entitled “Equipment for, and a method of, removing tissue from a site ina patient's body”. The entire contents of which are herein incorporatedby reference in its entirety.

Once the nuclear tissue has been removed, the methods may includechecking dimensions of the cavity so formed. Thus, the methods mayinclude using the at least one envelope, containing suitable markers, tocheck the dimensions and or position of the cavity. This may be effectedby inflating the at least one envelope using a suitable fluid such as awater/saline solution. Instead of using the at least one envelope withmarkers, the method may include using a flexible wire fed down theintroducer and checking the position of the wire using a fluoroscopicx-ray technique once the wire is in position. In a further way ofchecking the dimensions of the cavity, the methods may include deployingat least one jacket of similar dimensions to the at least one envelopein the cavity, inflating the jacket with the water/saline solution and,using a fluoroscope, detecting the periphery of the jacket by radioopaque markers on an outer surface of the jacket.

Once the at least one envelope has been placed in position, the methodsmay include checking the integrity of the at least one envelope, i.e. toensure that the at least one envelope does not have any leaks or otherdefects. This may be effected and affected by filling the at least oneenvelope with the water/saline or radioopaque solution.

The methods may include evacuating an interior of the envelope toinhibit the formation or entrapment of fluid bubbles in the fillermaterial. Instead, the methods may include commencing filling of theenvelope from a distal end of the envelope and progressively filling theenvelope towards a proximal end of the envelope (by withdrawing a fillertube or allowing the material buoyancy to lift the filler tube) toinhibit the formation or entrapment of fluid bubbles in the fillermaterial. In the latter case, either a delivery device by which theenvelope is introduced into the cavity or the envelope may define aformation allowing the escape of air, or gas, or certain fluids, as theenvelope is charged with the filler material. It may be desirable, incertain embodiments, to limit the formation or entrapment of bubbles, orto eliminate substantially the formation or entrapment of bubbles, inthe filler material. An advantage of minimising air or gas or certainfluid bubbles is that it maximises the volume occupied by thebiomaterial and the less voids (air bubbles) the implant has, it maymaximise the mechanical performance and stability from a fatigue andcreep resistance perspective. Any trapped air may be compressed insidethe envelope.

The methods may include, once filling of the at least one envelope hasbeen completed and a filler element withdrawn, occluding the aperture inthe tissue of the site. Occluding the aperture may comprise closing itoff by a non-return valve or by crimping closed a neck portion of theenvelope. A removable tube may be nested over the delivery device andmay be propelled distally to remove the at least one envelope and valvefrom the delivery device.

The methods may include attaching the at least one envelope to a distalend of a tubular delivery device and everting the at least one envelopeon the distal end prior to insertion of the delivery device into theintroducer for delivery of the envelope into the cavity of the site.

In certain exemplary embodiments, the method, or methods, may includeaccessing the site using an appropriate percutaneous surgical procedure.Hence, the method, or methods, may be used to perform less invasive (ascompared with minimally invasive and/or other surgical procedures)intervertebral disc nucleus replacement and may comprise forming anaperture in an annulus fibrosis of the disc percutaneously; extracting anucleus pulposus of the disc to form a disc cavity bounded by theannulus fibrosis of the disc and end plates of vertebrae between whichthe disc is located: inserting the at least one envelope, in asubstantially relaxed state (or first state), into the cavity throughthe aperture; charging the filler material into the at least oneenvelope to cause (or resulting in) the at least one envelope to expand(or second state) and conform, or substantially conform, to the shape ofthe disc cavity; allowing the filler material to cure to form, togetherwith the at least one envelope, the unified, or substantially unified,prosthesis; and occluding the aperture.

In certain exemplary embodiments, the method, may include accessing thesite using a percutaneous surgical procedure. Hence, the method may beused to perform less invasive intervertebral disc nucleus replacementand may comprise forming an aperture in an annulus fibrosis of the discpercutaneously; extracting a nucleus pulposus of the disc to form a disccavity bounded by the annulus fibrosis of the disc and end plates ofvertebrae between which the disc is located: inserting the envelope, ina first state, into the cavity through the aperture; charging the fillermaterial into the envelope to cause the envelope to expand and conformto the shape of the disc cavity; allowing the filler material to cure toform, together with the envelope, the unified prosthesis; and occludingthe aperture.

In certain exemplary embodiments, the methods include expanding andstretching the walls of the envelope and retaining the envelope undertension after charging it with filler material. In other embodimentswhere the cavity is relatively small, it may not be necessary for theenvelope to expand.

In an exemplary embodiment disclosed herein a method of forming tissueprosthesis, in situ is provided. In the exemplary method, a damagednucleus pulposus 18 of the disc 10 is removed and is replaced by anartificial prosthesis. Thus, as shown in FIG. 1 of the drawings, anintroducer 22 is inserted percutaneously into abutment with the disc 10.An aperture forming element in the form of a trocar 24 is inserted intoa lumen 26 of the introducer 22. A point 28 of the trocar pierces theannulus fibrosis 16 of the disc 10 forming an aperture 30 (FIG. 2) inthe annulus fibrosis 16 of the disc 10.

After the formation of the aperture 30, the trocar 24 is removed fromthe introducer 22. Once the trocar 24 has been removed, a nucleotomy isperformed on the disc 10. The nucleotomy involves the removal ofsufficient nuclear tissue constituting the nucleus pulposus 18. Whilevarious methods of removing the nucleus pulposus can be used (examplesof which are discussed throughout the specification), the example hereinshows the use of a mechanical device 32. The mechanical device 32comprises a reaming tool 34. The mechanical device 32 is insertedthrough the lumen 26 of the introducer and the aperture 30 in theannulus fibrosis 16 of the disc 10 into the nucleus pulposus 18. Thereaming tool 34 (FIG. 3) is operated to remove the nucleus pulposus asshown in FIG. 4 of the drawings so that a cavity 36 remains. The cavity36 is bounded by the annulus fibrosis 16 and the end plates 20 of thevertebrae 12 and 14. Residue 64 of the nucleus pulposus 18 remainsresulting in the cavity 36 having irregular walls.

In certain embodiments, an envelope 38 of an elastomeric material, moreparticularly, a silicone rubber material is mounted on a distal end of atubular delivery device 40. The tubular delivery device 40 defines apassageway 42 (FIG. 5). The envelope 38 may be made from the siliconerubber material which is biologically inert and which can elasticallydeform up to for example 3, 5, 7, 10, 20, 30, 40, 50, 60, 80, 100, 120,140, or 150 times the size of the envelope 38 in its relaxed state.

In an exemplary embodiment, as shown in greater detail in FIG. 10, theenvelope 38, in its relaxed, or deflated, state, is a snug fit over adistal end 44 of the delivery device 40. A first sleeve 46 is arrangedcoaxially over the delivery device 40 adjacent the distal end 44 of thedelivery device 40. This sleeve 46 may have a plurality of openings 48defined in it. These openings 48 cooperate with openings 50 at thedistal end 44 of the delivery device 40. A further sleeve 52 is mountedcoaxially about the sleeve 46 and communicates with an evacuation device(not shown) via an evacuating tube 54. Proximal ends of the sleeves 46and 52 are sealed against an outer surface of the delivery device 40 viaseals 56. A further seal 58 is arranged between a distal end of thesleeve 52 and the sleeve 46.

When filler material, referenced generally by the reference numeral 60(and discussed in more detail elsewhere herein), is injected into theenvelope 38, a low (e.g., lower than ambient) pressure may be,simultaneously, prior to injection, or a combination thereof imparted tothe delivery device 40 and or envelope 38 to manipulate (e.g. evacuate)fluid, more particularly, gases, from within the envelope 38. Thisassists in substantially airless mixing and helps ensure that theformation of gas bubbles in the filler material 60 is substantiallyinhibited. Evacuation of gases also helps inhibit entrapment of gaseswithin the envelope 38 by the incoming filler material 60 andfacilitates the flow of the filler material 60 into the envelope 38. Asthe filler material 60 is charged into the envelope 38 through thefilling openings 50, gas is drawn out of the envelope 38 by operation ofthe evacuation device via the evacuation tube 54. The gas is receivedbetween the outer surface of the delivery device 40 and the sleeve 46.This gas passes through the openings 48 in the sleeve 46 and through theevacuation tube 54.

In alternative embodiments (e.g., open and/or closed multi lumensystems), gas can be removed in other manners as well. For example, thefiller tube could be primed before it is inserted it into the envelope(or carrier) tube and deliver the biomaterial into the envelope.Alternatively, the envelope could be maintained in a collapsed state sothat the envelope does not need to be actively evacuated during anystages of the filling. In other embodiments, a first and second lumenmay be used to deliver fluid (one of course delivers low pressurefluid). The term deliver is not specifically directional towards theenvelope or away from the envelope. In a closed or open system scenario,the filling tube may extend (perhaps halfway or all the way to the end)into the envelope and as the envelope is filled, the fluid in theenvelope may be pushed out through a second lumen. In certainembodiments, the filling tube terminates at a point substantially inalignment with the proximal end of the envelope or just proximal to theenvelope. The filling tube may terminate substantially in line with thedistal end of the carrier tube, or just proximal to the distal end ofthe carrier tube. As the filler material is charged into the envelope,evacuation, or manipulation of fluid, or withdrawal of fluid, at leastfrom within the envelope may no longer be active, as the annular spacebetween the first and second lumen, which was in fluid communicationwith the interior of the envelope has been substantially occluded. In asingle lumen filling system, the envelope may be carried by the fillingtube (thereby the filling tube being both the filling tube and carriertube) and the fluid in the envelope may be vented around the space 1016between the filling tube 1014 and a valve 1012 on the envelope (see,e.g., FIGS. 96 and 97). In certain embodiments, a valve may not benecessary, so long as there is some clearance between the envelope andthe outside of the filling tube, fluid will be able to be pushed outfrom the envelope as the envelope fills with a biomaterial.

It may also be useful to monitor the shape and size of the cavity 36taking the residue 64 into account. This can be achieved in a number ofways. One of the ways in which this can be achieved is by having radioopaque markers 70 arranged on the envelope 38. Prior to charging theenvelope 38 with the filler material 60, the envelope 38 can be expandedto conform to the shape of the cavity 36 by means of a water/salinesolution or a radio opaque solution. The markers 70, being radio opaque,are monitored under a fluoroscope to determine the shape and size of thecavity 36.

Other methods of assessing the size of the cavity 36 include the use ofa flexible wire inserted down the lumen 26 of the introducer 22, thewire being monitored by a fluoroscope. Yet a further way of monitoringthe shape and size of the cavity 36 is by use of a dedicated jacket, ofsimilar dimensions to the cavity 36, which is inserted into the cavity36 and inflated using the water/saline solution or the radio opaquesolution. The jacket carries radio opaque markers which are monitored bya fluoroscope.

FIGS. 77-79 illustrate an embodiment of equipment for preparing a sitefor implantation of tissue prosthesis. The equipment 10 comprises aconduit assembly 12 carrying a member 14 at a distal end of the conduit12 assembly 12. The equipment 10 further may also include a plurality offluid dispensers 16 connectable to a proximal end of the conduitassembly 12 to communicate with the member 14. In certain aspects, themember may be sufficiently inflatable, resiliently flexible, able to beelastically deformed, or combinations thereof of these properties.

This equipment may be used to determine, or approximate, the size of acavity 18 formed in an intervertebral disc 20. The disc 20 has anannulus 22 surrounding a nucleus 24. Degeneration of the disc 20 mayresult in herniation of nuclear material of the nucleus 24 through theannulus 22. To repair a damaged disc 20, the nucleus 24 may replaced byan intervertebral disc prosthesis as described in the embodimentsdisclosed in this specification.

In addition, the equipment may also measure the position of the cavity.The position of the cavity as well as the position of the prosthesis maybe checked under the fluoroscope or other imaging means to check thecavity position laterally and in the anterior-posterior view (AP view).In other words, the sizing device can be viewed as a mock implant. Anadvantage of sizing the cavity and the position is that the remainder ofthe implant can actually be performed blind without the need of anyimaging assistance. This is because the working cannula will positionthe implant and the sizing device has determined for the surgeon thevolume required to fill the implant.

To prepare the site for implantation of the prosthesis, it may bedesirable to conduct a nucleotomy to remove portions, or substantialportions, of the nuclear material from the disc 20. However, in certaincircumstances, the nuclear material 24 may have either degenerated orherniated through the annulus 22 to a sufficient extent that a cavity 18is formed with can receive the tissue prosthesis to reconstruct theintervertebral disc 20. The amount of nuclear material that needs to beremoved may be expected to vary from situation to situation.

The member 14 may be made from a number of different materials. Incertain preferred embodiments, it is desirable that the member beinflatable, resiliently flexible and/or able to be elastically deformed.In certain embodiments, the member 14 could be of a silicone materialand may have similar or substantially the same characteristics of theenvelope of the applicants tissue prosthesis described herein.

In the exemplary embodiment illustrated, the equipment 10 comprises apair of fluid dispensers 16 each in the form of a syringe 26, 28. Thesyringe 26 has a barrel 30 and a plunger 32 slidably displaceable in thebarrel 30. Similarly, the syringe 28 has a barrel 34 and a plunger 36slidably displaceable in the barrel 34. Further, in this embodiment, theconduit assembly 12 comprises a first, outer conduit, or tube, 38. Theelement 14 is mounted on a distal end of the outer tube 38. An inner,filler conduit, or tube, 40 is co-axially arranged within the outer tube38. The filler tube 40 projects from the syringe 26 through a branchedconnector 42 arranged at a proximal end of the tube 38. The branchedconnector 42 may be a Y connector defining a primary lumen 44 throughwhich the tube 40 extends and a secondary, branched lumen 46. Thesyringe 28 is connected to a part 48 of the connector 42 defining thesecondary lumen 46.

In use, in this exemplary embodiment, the equipment 10 is insertedpercutaneously via a working cannula (not shown in these figures butdescribed elsewhere) so that the member 14 is received in the cavity 18of the disc 20. The equipment 10 is inserted percutaneously.

Initially, the equipment 10 may be primed. The priming of the equipment10 is effected and affected by drawing on the plunger 36 of the syringe28 in the direction of arrow 50. This may result in the member 14collapsing. Because the equipment 10 defines a closed system, orsubstantially closed system, it also results in the plunger 32 of thesyringe 26 being drawn in the direction of arrow 52. The syringe 26contains a volume measuring fluid. In certain embodiments, the volumemeasuring fluid may comprise non-compressible fluid, and/or fluids, suchas a liquid (e.g., but not limited to, a radioopaque dye (such asurografin), or water or a saline solution). In some aspects, the fluidmay be substantially non-compressible fluid and/or fluids. The equipment10 is regarded as being fully or substantially primed when the liquidfrom the syringe 26 begins to flow into the syringe 28.

The position of the plunger 36 of the syringe 28 may be fixed inposition as shown in FIG. 78. The plunger 32 of the syringe 26 is thenfurther pushed in the direction of arrow 52 to inflate the inflatablemember 14 fully. Instead of fixing the position of the plunger 36 in thesyringe 28, can be removed and a sealing cap (not shown) can be placedover the branch of the Y connector to maintain the closed orsubstantially closed system.

Referring to FIG. 79, the plunger 32 of the syringe 26 may be drawn inthe direction of arrow 54 to deflate the member 14. Inflation anddeflation of the member 14 using the syringe 26 is then repeated for anumber of cycles to condition the disc 20. The cyclicalinflation/deflation of the disc 20 increases the laxity of the disc 20and is generally referred to as “mobilising the joint”. By cycling themember 14 a number of times, surrounding residual nuclear material 55 inthe disc 20 may be compressed or compacted and is less likely tointerfere with the subsequently implanted nuclear prosthesis.

Once the disc 20 has been cycled a number of times, the plunger 32 ofthe syringe 26 may be drawn to a start position in which the member 14is, once again, substantially collapsed. It will be appreciated that,because the system is a closed system, and the plunger 36 of the syringe28 is locked in position, the plunger 32 of the syringe 26 will only beable to be withdrawn to a certain fixed, start position in the barrel 30of the syringe 26. In this position, the member 14 is substantiallycollapsed and the conduits 38 and 40 are filled with gas and/or liquid,respectively, it being appreciated that there will also be some liquidin the conduit 38. Depending on the degree of withdrawal of the piston36, conduit 38 may be composed completely or substantially of fluid(liquid) also. In this position, the equipment 10 is substantiallyprimed.

The plunger 32 of the syringe 26 is urged in the direction of arrow 52to displace the volume measuring liquid from the syringe 26 into theinflatable member 14. This fully inflates the member 14 so that itconforms to the shape of the cavity 18 in the disc 20. When the member14 fully conforms to the disc 18, any attempt to further displace theplunger 32 in the direction of the arrow 52 will result in a substantialincrease in pressure. This is therefore the end point indicating thatthe member 14 fully conforms to the cavity 18 of the disc 20 and theamount of liquid dispensed from the syringe 26 after priming of theequipment 10 is an accurate indication of the volume of the cavity 18.

As will be described in the embodiments described below with referenceto FIGS. 80-85, the plunger 32 may carry a transducer (not shown in thisembodiment). The transducer may, for example, be a pressure transducerand, when the sudden increase in pressure occurs, an enunciator may beactivated to indicate the end point.

Referring now to FIGS. 80-85, additional embodiments of equipment forpreparing a site for implantation of tissue prosthesis is described. Inthese embodiments, the conduit assembly 12 comprises a single tube 38 towhich the connector 42 is connected at a proximal end of the tube 38. Adistal end of the tube 38 caries the member 14.

In this embodiment, the connector 42 may be a T-connector defining theprimary lumen 44 and the secondary lumen 46. It will, however, beappreciated that the connector 42 could, as in the previous embodiments,be a Y-connector.

The conduit assembly 12 further includes a fluid control arrangement inthe form of a three way stopcock 56. The stopcock 56 is operable toplace either the lumen 44 of the connector 42 in fluid communicationwith an interior of the tube 38 or the lumen 46 of the connector 42 incommunication with the interior of the tube 38.

As in the case of the previous embodiments, the syringe 26 is connectedto the connector 42 to be in communication with the lumen 44 of theconnector 42. The syringe 28 is connected to the connector 42 to be incommunication with the lumen 46 of the connector 42. In use, in theseembodiments, the equipment 10 may be inserted percutaneously via aworking cannula (not shown).

To prime the equipment 10, the syringes 26 and 28 are operated. Moreparticularly, the stopcock 56 is positioned so that the lumen 46 isoccluded while the lumen 44 of the connector 42 is open. The plunger 32of the syringe 26 is urged in the direction of arrow 58. This causesinflation of the member 14. Some liquid from the syringe 26 will enterthe member 14 and so will gas which was present in the equipment 10. Thefluid from the syringe 26, being heavier than the gas, will sink to thedistal end of the member 14. The gas in the equipment 10 will bedisplaced to be arranged near the distal end of the tube 38.

Withdrawal of the piston 32 of the syringe 26 in a direction of arrow 59will draw out the gas from the tube 38 and, subsequently, fluid from themember 14 as well. These steps may be repeated a number of times toensure that the equipment 10 is fully primed. The equipment 10 isregarded as being fully primed when the piston 32 of the syringe 26 isdrawn to the position shown in FIG. 82 in which the member 14 issubstantially collapsed.

It should be appreciated that the priming method described above isapplicable when the inflating member is pointing down (i.e., as it wouldbe the case if the device were positioned in the disc) and the fillingtube/member stops at the proximal junction to the inflation member. Forthe case where the filling tube extends into the distal part of theinflating member, the priming should occur with the inflating memberpointing up (i.e., or as the case may be, primed before being positionedinto the disc). This is because when the fluid is ejected from thesyringe to prime the system, the buoyancy of the gas may force the gastowards the distal part of the inflatable member where the lumen of thetube is.

With the piston 32 of the syringe 26 in the position shown in FIG. 82,the stopcock 56 is switched to occlude the lumen 44 of the connector 42and to open the lumen 46 of the connector 42 (see FIG. 83). This placesthe syringe 28 in communication with the interior of the tube 38 and theinterior of the member 14. The syringe 34 contains a volume measuringliquid (e.g., water or a saline solution).

The plunger 36 of the syringe 28 is urged in the direction of arrow 60(FIG. 84) to inflate the member 14 fully so that it substantiallyconforms, or at least partially conforms to the shape of the cavity 18of the disc 20. The plunger 36 of the syringe 28 is then drawn in thedirection of arrow 62 (FIG. 85) to cause deflation of the member 14. Theplunger 36 is cycled a number of times to inflate and deflate the member14 to condition the disc 20 as described in this specification.

After conditioning the disc 20, the plunger 26 is drawn to a zeroingposition in the syringe 28. It will be appreciated that, because theequipment 10 defines a closed system, or substantially closed system,the plunger 36 can only be withdrawn to a certain, fixed position in thesyringe 28. This position occurs when the member 14 is sufficientlycollapsed. In this zeroing position, the plunger 38 is, once again,urged in the direction of arrow 60 to inflate the member 14 fully sothat it conforms, or substantially conforms to the cavity 18 of the disc20. It will be appreciate that, when the member 14 has been fully orappropriately inflated, further attempts to displace the plunger 36 inthe direction of arrow 60 will typically result in a sudden or steepincrease in pressure. The pressure is recorded by a pressure transducer64 carried on the plunger 36 of the syringe 28. The transducer 64 isconnected to a transducer readout 66 which contains an enunciator. Theenunciator may be an audible and/or visual enunciator to alert anoperator that the end point has been reached and that the member 14 isfully, or appropriately, inflated. The volume of liquid displaced fromthe syringe 28 represents the volume of the cavity 18 of the disc 20.Since the radioopque dye being injected is significantly incompressible,there is a significant difference (steep pressure rise) in theresistance to further displacement of the syringe piston 36 when themember 14 has been inflated to capacity, thus the tactile feedback is asensitive enough indication in being able to gauge the endpoint offilling. The feedback which the surgeon receives from the resistance ofthe syringe piston 36 is significantly sensitive for the surgeon to beable to gauge the endpoint of filling.

In certain embodiments disclosed herein, the conduit assembly 12 may actas a stiffening member for the member 14. Thus, in certain embodiments,the filler tube 40 may extend to a distal end of the member 14 asindicated by dotted lines 68 in FIGS. 78 and 80 of the drawings. Theextension 68 of the filler tube 40 has a slot 70 defined in it to placethe interior of the member 14 in communication with the interior of thefiller tube 40 to allow inflation and deflation of the member 14. Inthese embodiments, when the member 14 is substantially collapsed, it iscollapsed about the extension 68 of the filler tube 38. Similarly, inthe embodiments described with reference to FIGS. 80-85, the tube 38 ofthe conduit assembly 12 may have the extension 68 with the slots 70defined in the extension 68. In these embodiments, it may be desirableto prime the equipment 10 externally of the patient as gas needs to moveto a top of the member 14 with the equipment 10 being held vertically sothat the member 14 is at the top of the equipment 10. In certainembodiments, the equipment 10, whether with the extension 68 of thefiller tube 40 or not, can be primed when the equipment 10 is positionedwithin the patient. In general, the equipment 10 should be able to beprimed so that an accurate measure of the volume of a cavity to receivetissue prosthesis can be determined. In addition, by cycling theinflatable member, the surrounding tissue can be conditioned forreceiving the tissue prosthesis.

After the shape and size of the cavity 36 have been determined, thefiller material 60 is dispensed from the dispenser 62 and is monitoredvia the sensing arrangements 66 or 68, as the case may be. Asillustrated in FIG. 7 of the drawings, the filler material 60 causeselastic expansion or inflation of the envelope 38 so that the envelope38 conforms to the shape of the cavity 36 and bears against the residue64 of the nucleus pulposus remaining in the cavity 36. The envelope 38,having been elastically expanded by the filler material 60, remainsunder tension around the filler material 60 while conforming to theshape of the cavity 36.

Backflow filler material 60 from the interior of the envelope 38 may becontrolled either by a valve 72 as shown in FIG. 13 of the drawings orby a clamping device 74 as shown in FIG. 7 of the drawings. The valve 72is a duckbill valve and acts as a one way valve so that backflow offiller material 60 from the envelope 38 is substantially restricted orinhibited.

Once the envelope 38 has been filled and has expanded so that itconforms closely, sufficiently, and/or substantially to the shape of thecavity 36 and is received snugly in the cavity 36, the filler material60 is allowed to cure for a predetermined period of time of for example,about 5, 10, 15, 20, 25 or 30 minutes. After substantial curing of thefiller material 60, the delivery device 40 is removed (alternatively, asdescribed elsewhere herein, the delivery device 40 may be removed afterdelivery of the filler material 60 but before curing) leaving theaperture 30 occluded as shown at 76 in FIG. 8 of the drawings. Theunified tissue prosthesis 100 so formed is preferably, substantiallycured after about 15 minutes.

To facilitate removal of the delivery device 40 from the envelope 38,the envelope 38 may incorporate a zone of weakness in the form of acircumferential groove 78 (FIG. 14) formed at a proximal end. The zoneor area of weakness may be achieved in a number of different manners aswell, for example, but not limited to, being built in during themanufacturing process. As the delivery device 40 is withdrawn, when itsdistal end comes into register with the groove 78, the delivery device40 is twisted relative to the envelope to cause a break at the groove 78to form the occlusion 76 in the aperture 30 of the annulus fibrosis 16of the disc 10. In certain embodiments, the occlusion 76 may be formedas a result of the annular fibers closing over the aperture after thedelivery device has been removed.

FIG. 12 shows another way of delivering the envelope 38 into the cavity36 in accordance with certain embodiments. In FIG. 12, the envelope 38is everted to lie within the distal end of the delivery device 40 tofacilitate its insertion into the cavity 36. A similar arrangement isshown in FIG. 9 and FIG. 14.

In FIG. 11, another embodiment of equipment for forming the tissueprosthesis 100 is shown. In this embodiment, a filler tube 80 is used.The tube 80 is received in the passageway 42 of the delivery device 40.A sleeve 82 is arranged coaxially about the delivery device 40. A firstdisplacement device, such as a trigger, 84 is provided for controllingrelative movement between the delivery device 40 and the tube 80. Asecond displacement device, which may also be in the form of a trigger,86 controls relative movement between the delivery device 40 and thesleeve 82.

The equipment, as shown in FIG. 11, is for use where an evacuatingdevice is not used. Thus, to fill the envelope 38, the tube 80 is urgedtowards the distal end of the envelope 38 and charging of the fillermaterial 60 into the envelope 38 commences at the distal end of theenvelope 38. Filling of the envelope 38 progresses from its distal endtowards its proximal end. Thus, as filler material 60 is charged intothe envelope 38, the tube 80 is slid proximally relative to the tube 40by manipulating the trigger 84 or slides back through buoyancy of thefiller material. Once the envelope 38 is in its fully inflated state,the envelope 38 is urged off the distal end of the delivery device 40 bymanipulating the trigger 86. As the tube 80 is withdrawn from the valve72 and the envelope 38 is removed from the distal end of the deliverydevice 40, the valve 72 closes to form the occlusion 76. To facilitateexpulsion of gas when an evacuating system is not being used, theenvelope 38 has a bead 88 (FIG. 12) formed along that portion whichseats on the distal end of the delivery device 40 to create passages 90through which air or gas or certain fluids can be discharged as theenvelope 38 is charged with the filler material 60.

The envelope 38 may be constructed of a silicone rubber material whichcan be inflated up to about 5, 10, 15, 25, 50, 75, 100, or 150 times itsrelaxed size without rupturing. In certain embodiments, the envelope 38may be made of less expansible material such as a biological or asynthetic polymeric material. A suitable synthetic polymeric materialmay, for example, be a polyester such as polyethylene terephthalate(PET). The envelope 38 may be constructed of a knitted PET material sothat, when the filler material 60 is charged into the envelope 38, thefiller material fills foramens or interstices in the envelope 38 to forman integrated structure which resists relative movement between thefiller material 60 and the envelope 38. Alternatively, the knitted PETmaterial may be coated with silicone allowing the filler material 60 tointegrate with the coating.

FIGS. 15 to 17 show different shapes of envelopes 38 which can be useddepending on which intervertebral disc 10 is to have its nucleuspulposus 18 replaced. Additional detail regarding the envelopes isprovided elsewhere herein.

FIGS. 18 to 21, show further embodiments of equipment for forming atissue prosthesis, in situ, at a site in a patients body is illustrated.In these embodiments, the equipment 110 comprises a delivery device inthe form of an envelope tube 112. The envelope tube 112 carries theenvelope 38 at its distal end.

A filler member in the form of a filler tube 114 is slidably receivedwithin a passage 116 of the envelope tube 112. As illustrated in FIG.21, the filler tube 114 has a smaller outer diameter than an innerdiameter of the envelope tube 112 to form an annular gap 118 between thefiller tube 114 and the envelope tube 112.

A removal mechanism in the form of a push-off tube 120 is a snug fit onthe outer surface of the envelope tube 112.

In certain embodiments, the envelope 38 is of a two part constructioncomprising a sleeve 122 (FIG. 21) to which an envelope defining member124 is adhesively bonded as shown by an annular adhesive layer 126. Thesleeve (and hence the valve) may be molded into the envelope definingmember via insert molding or alternatively, the molded envelope mayinclude a valvular member. The sleeve 122 defines the valve 72. Formaterials other than silicone, the sleeve may be welded (hot or cold),insert molded (or overmolded), onto the envelope defining member.Alternatively, the sleeve and the envelope defining member may be heldtogether by a friction fit. Combinations of all of the above may also beapplicable.

A distal end of the filler tube 114 carries an engaging member 128 whichengages and opens the valve 72 so that the annular gap 118 is in flowcommunication with an interior 130 of the envelope 38. A distal end ofthe push-off tube 120 terminates short of a proximal end of the sleeve122 of the envelope 38. However, it is also to be noted, that theenvelope tube 112 is displaceable relative to the push-off tube 120 inthe direction of arrow 132. Instead of the engaging member 128, thevalve 72 could have a small opening (not shown) in it. The size of theopening in the valve 72 is selected to allow the passage of air, gas andcertain other fluids through it in a particular direction or directions,but is sufficiently small that the viscosity of the filler material willsubstantially restrict or inhibit the passage of the filler materialthrough it in a particular directions or directions.

Yet a further way of evacuating the interior 130 of the envelope 38 isto insert the filler tube 112 into the interior 130 of the envelope 38and to have a slit (not shown) in the filler tube 114 upstream of thevalve 72. Thus, if the valve 72 seals about the filler tube 112, air canstill be drawn from the interior 130 of the envelope 38 into the gap 116via the slit when the evacuation device is operated.

A proximal end of the envelope tube 112 carries a connector 134. Theconnector 134 is a Y-connector having a primary member 136 and asecondary member 138 projecting from the primary member 136. Theenvelope tube 112 is fast with the primary member 136 of the connector134. The secondary member 138 of the connector 134 is in flowcommunication with the passage 116 of the envelope tube 112 and, hence,in use with the gap 118 between the envelope tube 112 and the fillertube 114. The secondary member 138 is connectable to an evacuationdevice (not shown) such as an evacuation pump for creating a lowpressure in the gap 118 and, via the engaging member 128 opening thevalve 72, the interior 130 of the envelope 38 prior to filler materialbeing charged into the interior 130 of the envelope 38.

As shown in FIG. 20, the connector 134 includes a retaining mechanism140 for retaining the envelope tube 112 in position relative to theintroducer 22. The retaining mechanism 140 comprises a receivingformation 142 carried at a proximal end of the introducer 22. Theretaining mechanism 140 further includes a clip portion 144 forming thedistal end of the connector 134 which clips into the receiving formation142 to retain the envelope tube 112 in position relative to theintroducer 22.

A proximal end of the push-off tube 120 carries a gripping formation 146which is accessible externally of the retaining mechanism 140 forenabling the push-off tube 120 to be held while the envelope tube 112 ismoved in the direction of the arrow 132 after charging of the envelope38 with the filler material.

The equipment 110 may further include a dispensing device 148 fordispensing filler material. The dispensing device 148 includes adispenser 150 feeding into a mixing device in the form of a static mixer152. A distal end of the static mixer 152 carriers the filler tube 114.A Luer lock arrangement 154 is arranged at the distal end of the staticmixer 152 and connects the dispensing arrangement 148 to the connector134.

In certain embodiments, the filler material is of a silicone rubber. Toinhibit curing of the filler material prior to its being charged intothe envelope 38, the filler material is retained in two, separate parts.Thus, the dispenser 150 includes two reservoirs 156 in each of which apart of the filler material is initially received. Each reservoir 156has a plunger 158 associated with it for dispensing the parts from thereservoirs 156 into the static mixer 152 where the parts are mixed priorto being charged into the envelope 38. It is to be noted that theplungers 158 are displaceable together with each other via a suitabledisplacing device (not shown) such as a pneumatic gun.

Thus, in use, the filler material to be charged into the envelope 38 isprovided in the dispensing arrangement 148. The dispensing arrangement148 is connected to the connector 134 via the Luer lock 154. An envelope38, in a deflated condition, is mounted on the envelope tube 112. Afterthe nucleotomy has been performed on the disc 10, the envelope tube 112with the envelope 38 on its distal end is inserted through theintroducer 22 so that the envelope 38, in its deflated condition, isreceived within the cavity 36 of the disc 10. The filler tube 114 isinserted into the interior of the envelope tube 112 so that the engagingmember 128 engages the valve 72 and opens the valve 72. By opening thevalve 72, the interior 130 of the envelope 38 is placed in fluidcommunication with the gap 118 between the envelope tube 112 and thefiller tube 114.

An evacuation device (not shown) is attached to the secondary member 138of the connector 134 and a vacuum is drawn. This creates a lowerpressure within the gap 118 and the interior 130 of the envelope 38 andinhibits the formation of gas bubbles in the prosthesis 100 as thefiller material is charged into the envelope 38.

The filler material is dispensed from the dispensing device 148 into thefiller tube 114 and into the interior 130 of the envelope 38. Thiscauses the envelope 38 to expand elastically to conform to the shape ofthe cavity 36 of the disc 10 with the envelope 38 being retained undertension by the filler material.

After charging of the filler material into the interior 130 of theenvelope 38, the filler tube 114 is withdrawn. Withdrawal of the fillertube 114 causes withdrawal of the engaging member 128 allowing the valve72 to close to inhibit leakage of filler material from the interior 130of the envelope 38.

After curing, the envelope tube 112 is moved relative to the push offtube 120 in the direction of the arrow 132 by holding the push off tube120 using the gripping device 146. This urges the sleeve 122 of theenvelope 38 off the end of the envelope tube 112 as the envelope tube112 is withdrawn relative to the push off tube 120. The valve 72occludes the opening to the envelope 38. The equipment 110, includingthe introducer 22, is then withdrawn from the patient's body, allowingthe aperture 30 to occlude as the fibres of the annulus fibrosis 16close over and the procedure is complete.

FIGS. 22 to 24, illustrate further embodiments of equipment for forminga tissue prosthesis, in situ, at a site in a patient's body isillustrated. The equipment 110 includes a stiffening element in the formof a stiffening rod or tube 160. Prior to insertion of the filler tube114 into the envelope tube 112, the stiffening rod 160 is inserted intothe passage 116 of the envelope tube 112. A distal end 162 of thestiffening rod 160 projects beyond a distal end of the envelope tube 112and terminates at a distal wall in the interior 130 of the envelope 38.A gap 161 is created between the envelope tube 112 and the stiffeningrod 160. The gap 161 and the interior 130 of the envelope 38 areevacuated by operation of the evacuation device to cause the envelope 38to collapse on to the distal end 162 of the stiffening rod 160. Thisfacilitates insertion of the envelope 38 into the introducer 22 and intothe cavity 36 of the disc 10.

Once the envelope 38 has been located within the cavity 36, theevacuation device is turned off to release the envelope 38 from thedistal end 162 of the stiffening rod 160 and this allows the stiffeningrod 160 to be withdrawn. The filler tube 114 can then be inserted intothe envelope tube 112, as described above, to enable filler material 60to be charged into the envelope 38.

In certain embodiments (not illustrated), the stiffening rod 160 isdimensioned to fit in the interior of the filler tube 114. With thisarrangement, the gap 118 between the envelope tube 112 and the fillertube 114 is evacuated, as described above, with the stiffening rod 160projecting through the distal end of the envelope tube 112 and theenvelope 38 being collapsed over the distal end 162 of the stiffeningrod 160.

A proximal end 164 of the stiffening rod carries a cap connector 166which connects to the Y connector 134 to retain the stiffening rod 160in position relative to the envelope tube 112 and/or the filler tube118, as the case may be. The cap connector 166 seals against a proximalend of the Y connector to enable the fluid and or the fluid pressure inthe gap 161 and the interior 130 of the envelope 38 to be manipulatedthrough operation of the withdrawal device, connected to the Y connector134 (the port which does not have the cap connector 166 attached to it).Such a withdrawal device may be a syringe.

In additional exemplary embodiments, there may be provided a prosthesisdelivery system which includes a plurality of nested tubes, an outermosttube of which functions as a cannula in which the remaining tubes arereceived, the remaining tubes forming part of a prosthesis deliveryapparatus, a wall portion of at least one of the tubes having a changein diameter along its length to mate with a corresponding part of adispensing arrangement for use with the prosthesis delivery apparatus.

The prosthesis delivery devices may include a carrier tube which carriesa component of the prosthesis on its distal end and a filler tubereceived in the carrier tube for charging a filler material into thecomponent when the component is located at the desired location at asite in a patient's body. The prosthesis delivery apparatus may includea connector for connection to a withdrawal device to enable gas to bewithdrawn from the component during formation of the prosthesis in situ,the connector being arranged, in use, at a proximal end of theprosthesis delivery apparatus. Further, the prosthesis deliveryapparatus may include a displacement device for displacing the componentof the prosthesis after it has been charged with the filler material.The displacement device may be a further tube mounted about the carriertube. In addition, the prosthesis delivery apparatus may include a covertube to cover the component of the prosthesis, the cover tube fittingover the carrier tube. The cover tube may include a resiliently flexibledistal portion to accommodate the component of the prosthesis. Incertain embodiments, the prosthesis delivery apparatus may include aconnector for connection to a withdrawal device to enable gas to bewithdrawn, or manipulated, or evacuated from at least the componentduring formation of the prosthesis in situ. More specifically andpreferably, the withdrawal device may manipulate the fluid and or fluidpressure at least within the delivery apparatus and or the envelope,when in use. Although the fluid and or the fluid pressure manipulationremains active whilst the filler material is being charged down thefiller tube, once the material reaches the distal end of the filler tube(i.e., The proximal end of the component/envelope), the annularspace/gap between the filler tube and the carrier tube is occluded bythe filler material. Hence during the formation and filling of theenvelope, the fluid and or fluid pressure manipulation of at least theinterior of the envelope is no longer active

In certain embodiments, a wall portion of each of the tubes may have achange in diameter along its length. The change in diameter along thelength of each tube may be provided by a flared wall portion of eachtube.

The disclosed systems may include a manipulating arrangement carried ata proximal end of at least the cannula for effecting manipulation of thenested tubes. The manipulating arrangement of the cannula may include arupturing mechanism for rupturing the cannula for removal. The rupturingmechanism may include a plurality of circumferentially spaced,longitudinally extending zones of weakness in a wall of the tube of thecannula and a gripping device arranged at a proximal end of the tube ofthe cannula. The gripping device may comprise a plurality ofcircumferentially spaced radially outwardly extending tabs which arepulled outwardly to cause rupturing of the zones of weakness of thecannula to facilitate withdrawal of the cannula after placement andsetting of the prosthesis.

The systems may include the dispensing mechanism, the dispensingmechanism including a tubuldar element having a distal end whichcorresponds with and mates with that part of the wall portion of the atleast one tube having the change in diameter. The nested tubes may beconfigured to extend proximally of the distal end of the element tooverlie the element. With this arrangement, the length of theunsupported ends of the tubes is considerably shortened therebyimproving the rigidity of the tubes and the stability of the system. Inaddition, the balance of the system is improved rendering it easier forthe clinician to control system.

The dispensing mechanism may include a dispenser to which the element isattachable. The element may be a static mixer.

In certain embodiments, there are provided systems which includes aplurality of tubes, wherein an outermost tube functions as a cannula inwhich the remaining tubes are received, the remaining tubes forming partof a prosthesis delivery apparatus, a wall portion of at least one ofthe tubes having a change in diameter along its length to mate with acorresponding part of a dispensing arrangement for use with theprosthesis delivery apparatus.

In certain embodiments, the prosthesis delivery devices may include atleast one carrier tube which may carry at least one component of theprosthesis on its distal end and at least one filler tube received inthe carrier tube for charging a filler material into the component whenthe component is located at the desired location. The prosthesisdelivery apparatus may include a connector for connection to awithdrawal device to enable gas and or certain fluids to be withdrawnfrom the component during formation of the prosthesis in situ, theconnector being arranged, in use, at a proximal end of the prosthesisdelivery apparatus.

In certain embodiments, the prosthesis delivery apparatus may include adisplacement device for displacing the component of the prosthesis afterit has been charged with the filler material. The displacement devicemay be a further tube mounted about the carrier tube.

In certain embodiments, the prosthesis delivery apparatus may include atleast one cover tube to cover the component of the prosthesis, the atleast one cover tube fitting over the at least one carrier tube. The atleast one cover tube may include a resiliently flexible distal portionto accommodate the component of the prosthesis.

In certain embodiments, a wall portion of each of the tubes has a changein diameter along its length. In some aspects, the change in diameteralong the length of each tube may be provided by a flared wall portionof each tube.

In certain embodiments, the system may include a manipulatingarrangement for effecting manipulation of the tubes located within thecannula. The manipulating arrangement may include a rupturing mechanismfor rupturing the cannula for removal. The rupturing mechanism mayinclude a plurality of spaced zones of weakness in a wall of the tube ofthe cannula and a gripping device arranged at a proximal end of the tubeof the cannula. The gripping device may comprise a plurality ofoutwardly extending tabs which are pulled outwardly to cause rupturingof the zones of weakness of the cannula to facilitate withdrawal of thecannula after placement and setting of the prosthesis.

In certain embodiments, the system may include the dispensing mechanism,the dispensing mechanism including a tubular element having a distal endwhich corresponds with and mates with that part of the wall portion ofthe at least one tube having the change in diameter. The nested tubesmay be configured to extend proximally of the distal end of the elementto overlie the element. With this arrangement, the length of theunsupported ends of the tubes is shortened thereby improving therigidity of the tubes and the stability of the system. In addition, thebalance of the system is improved rendering it easier for the clinicianto control system.

In certain embodiments, the dispensing mechanism may include a dispenserto which the element is attachable and/or the element may be a staticmixer.

In certain exemplary embodiments, there may be provided a prosthesisdelivery system which includes a plurality of nested tubes, one tubebeing a carrier tube which carries at least a component of a prosthesisat its distal end and another tube constituting a delivery tube fordelivering the nested tubes to a site at a patient's body: and a covertube forming part of the nested tubes, the cover tube being arrangedoutwardly of the carrier tube to cover the component when the carriertube is inserted into the delivery tube to protect the component. Thecover tube may have a length approximating a length of the delivery tubewith the carrier tube being dimensioned so that the component protrudesbeyond a distal end of the delivery tube in an uncovered condition.

In certain exemplary embodiments, the system may include a displacementdevice arranged outwardly of the carrier tube with the cover tube beingarranged outwardly of the displacement device. The displacement devicemay be a further tube mounted about the carrier tube. The cover tube mayhave a resiliently flexible distal end to accommodate the component ofthe prosthesis. The resilient flexibility of the distal end of the covertube may be affected and effected by slotting the distal end to providea plurality of leaves able to flex radially outwardly.

The equipment may include at least one sensing arrangement configured tosense a parameter of the filler material charged into the at least oneenvelope. The at least one sensing arrangement may comprise a pressuresensor for sensing the pressure of filler material charged into the atleast one envelope, a temperature sensor for sensing the temperature ofthe filler material charged into the at least one envelope, beconfigured to sense the quantity of filler material charged into theenvelope and/or comprise a flow rate sensor for sensing the rate of flowof the filler material into the at least one envelope. Further, the atleast one sensing arrangement may be configured to sense the presence ofgas bubbles in the filler material charged into the at least oneenvelope. Further, the sensing arrangement may be configured to sensethe displacement of the pistons of the dispenser mechanism. Further, thesensing arrangement may be configured to sense the force applied to thepistons to displace the pistons of the dispenser mechanism.

In certain embodiments, there may be provided equipment for forming atissue prosthesis in situ at a site in a patient's body, the equipmentcomprising a tubular delivery device, the delivery device defining apassageway, and at least one envelope of the prosthesis being mountableto a distal end of the delivery device to be received in a cavity at thesite; a stiffening element arranged to project from a distal end of thedelivery device with the envelope, in use, being received over thestiffening element to be supported by the stiffening element; and aremoval mechanism carried by the delivery device for enabling the atleast one envelope to be removed from the delivery device after the atleast one envelope has been charged with filler material via the fillermember.

In certain embodiments, the stiffening element may be an elongateelement, such as a rod or tube, receivable with clearance in thepassageway of the delivery device to define a gap to enable at leastsome fluid to be withdrawn from the at least one envelope to collapsethe envelope on to a distal end of the elongate element projecting fromthe distal end of the delivery device.

The equipment may include a filler member receivable in the passagewayof the delivery device after removal of the stiffening element, thefiller member being receivable, after removal of the stiffening element,with clearance in the passageway to define a gap to enable fluid to beevacuated at least from the at least one envelope.

In certain embodiments, the equipment may include a tubular fillermember receivable in the passageway of the delivery device, the fillermember being receivable with clearance in the passageway to define a gapto enable fluid to be evacuated at least from the envelope and thestiffening element being an elongate element receivable through thepassage of the filler member.

In certain embodiments, there may be provided a tissue prosthesisinsertion system which includes a first assembly comprising a pluralityof nested tubes, one of the tubes being a carrier tube which, in use,receives a component of a tissue prosthesis at a distal end of thecarrier tube; a magnetic mount carried at a proximal end of the firstassembly; a second assembly removably attachable to the first assembly;and an attachment device carried at a distal end of the second assembly,the attachment device being responsive to the magnetic mount of thefirst assembly, the magnetic mount and the attachment device carryingcomplementary engaging formations to facilitate sealing between themagnetic mount and the attachment device.

The use of a plurality of nested tubes, as described herein, may haveseveral advantages. For example, the device may be more compact thanother devices which allow the device and all of its components to fitinto a smaller confinement. This may, in certain embodiments, provide ameans for conducting percutaneous and/or minimally invasive procedures.The nested tubes also reduce trauma to the tissue that can result fromrepeatedly moving instruments in and out of the body. The nested tubesalso provide additional protection for the instruments inside of theoutermost tube. Additionally, the device can be more easily maintainedin its desired location and the system may operate with less frictionalresistance. Since the working cannula is fixed and docked relative tothe patient, and all the other nested tubes lock to the working cannula,the positioning and deployment of the envelope within the disc space isconsistent and repeatable. Also, since all the tubes are fixed relativeto each other, during any process of the implant procedure, the risk ofdamage to the envelope is minimised because movement (laterally and oraxially) of the envelope is minimised. Excessive movement of theenvelope during any part of the implant procedure increases its chancesof being damaged by either the surrounding tissue or other tubes (inparticular the working cannula).

The complementary engaging formations of the magnetic mount and theattachment device may comprise a Luer slip fitting (see, e.g., the luerslip fitting mechanism 1006 of FIG. 94). By “Luer slip fitting” is meantthat one of the engaging formations comprises a tapered socket and theother of the engaging formations comprises a tapered fitting receivablein the tapered socket to form a sufficient or substantial seal betweenthe fitting and the socket.

In certain embodiments, instead of a luer slip fit formation, sealingcan be achieved through the use of an O-ring or a gasket between thesurfaces of the mounts such that a substantial seal if formed.

Also, one engaging end can have a protruding member, in the form of atapered fitting, and the receiving end may comprise an engagingformation (not necessarily tapered) which is substantially parallel, butof a softer material than the protruding member such that it deforms toaccommodate the protruding member and form a seal. Two surfaces ofdissimilar materials (dissimilar hardness) engaging with mechanicalinterference may provide a substantial seal. For two surfaces of similarmaterials engaging with mechanical interference, to improve the seal, adissimilar material (e.g. Silicone) can be used between the two surfacesto provide a substantial seal. Also the applicant of a sealant betweenthe two similar surfaces can provide the necessary seal. FIG. 92illustrates the use of an O-ring 1000 between the two surfaces. Althoughnot illustrated, the seal could also be formed at the interface 1002 ofthe two surfaces.

The magnetic mount of the first assembly may be a first magnetic mountand the attachment device may comprise a second magnetic mount whichmagnetically attaches to the first magnetic mount.

In certain embodiments, both mounts do not necessarily have to bemagnetic, as long as one is magnetic, the other can be of a materialwhich is attracted to a magnet.

Alternatively, another means of engaging two surfaces is through theapplication of an adhesive on one or more of the surfaces and using thetackiness of the surfaces as a means for engaging the two surfaces.

Other means of coupling can include a luer lock connection (see, e.g.,the luer locking mechanism 1004 of FIG. 93), bayonet connection, ballseal connection and any other connection which allow the two engagingcomponents to be reversibly attachable. To achieve the closed systemstatus, any of the listed engaging means can be used in conjunction withany or all of the above mentioned sealing mechanisms either singly or incombination.

The second assembly may include a stiffening member received within thefirst assembly, the stiffening member, in use, projecting into aninterior of the component of the prosthesis, the stiffening memberhaving a securing formation at its proximal end which engages theengaging formation of the magnetic mount in a sealing manner.

Further, the system may include a withdrawing device attachable to thefirst assembly, the withdrawing device, in use, being in communicationwith the interior of the component of the prosthesis and, with thestiffening member in position, creating a closed system, containedsystem, or hermetically sealed system so that operating the withdrawingdevice causes an increase in the volume of the closed system with acorresponding reduction in the pressure in the interior of thecomponent, resulting in the component collapsing about the stiffeningmember.

The withdrawing device may be operable to test the integrity of thefirst assembly with the component mounted on the first assembly.

The first assembly may include a protective sheath, constituting one ofthe tubes of the first assembly, received over the component after ithas been collapsed on to the stiffening member. At least one of theprotective sheath and the component may be treated to facilitate slidingdisplacement between the protective sheath and the component. Thetreating of the protective sheath and/or the component may occur priorto inserting the first assembly into a working cannula used forinsertion of the tissue prosthesis into position at a site in apatient's body. The treating may involve immersing the distal end of thefirst assembly in a lubricating fluid such as water. Instead, thetreating may involve coating an inner surface of the protective sheathwith a hygroscopic material or a hydrophilic material such as, forexample, a hydrogel. Alternatively, rather than treating the innersurface of the protective sheath, the protective sheath itself may bemade from lubricious materials which include, but not limited to,polytetrafluoroethylene (Teflon), acetal, polypropylene, polyethylene.All of the above mentioned materials may also be a treatment option forthe inner lining of the protective sheath. Further, should theprotective sheath be made from the described polymers, they may also betreated to improve the lubricity.

The protective sheath may have a distal end configured to facilitatesliding displacement of the protective sheath relative to the componentof the prosthesis. In some aspects, the distal end of the protectivesheath may be configured by being bifurcated. The protective sheath mayinclude an operating member arranged at its proximal end to facilitatemanipulation of the protective sheath.

The systems may include the component, the component comprising at leastone envelope of an elastically deformable material, the at least oneenvelope defining an access opening with a flow control member beingarranged in the access opening, the flow control member being configuredto permit withdrawal of fluid from an interior of the at least oneenvelope prior to filling the at least one envelope with a fillermaterial. The flow control member may be a flow control valve which, ina rest condition, defines a withdrawal opening to allow withdrawal ofthe fluid from the interior of the at least one envelope. In certainaspects, the valve may be a duckbill valve having a pair of opposedoperating flaps, the flaps being shaped so that, in their restcondition, they are spaced from each other to define the withdrawalopening The flaps may be skewed or staggered so that when the flaps cometogether, a small opening is defined. Other types of valves includeumbrella valves, star valves, valves which have at least 1 flap(preferably 2), ball valve, dome shaped (e.g., umbrella shaped) valvewith a slit(s) cut into the very tip of the dome. For example, FIGS. 87and 88 illustrate an exemplary ball valve in an open and closedposition, respectively and FIGS. 89 and 90 illustrate an exemplaryumbrella valve in an open and closed position, respectively. The valvemay be pressure sensitive whereby it prevents flow in a particulardirection at a certain pressure. When that certain pressure is exceeded,it allows for fluid to flow in that particular direction.

In certain embodiments, the flow control member may not necessarily haveto be a valve. If the neck of the envelope were inverted, once theenvelope has been filled, the inverted neck would form a flap whichseals to prevent the backflow of material. The inverted neck may beparallel (tubular), tapered or stepped (i.e., the diameter changes).Also, another alternative to a valve (which is built into the envelope)is a tubular section which has a gradual reduction in diameter (See, forexample, FIG. 91). This functions like a valve but may not necessarilybe referred to as a valve. Various cross sections are possible for thisform of flow restricting mechanism. It still has an opening in itsrelaxed state but once the envelope is filled, the significantly moreviscous biomaterial cannot flow back out. All of the above mentioneddesign features can be applicable for a valve or a valve like structurewhich does not have an opening defined in its relaxed state. It couldrequire an extending member (either an extension of the carrier tube orother) to open up the valvular member in order to define this opening,which may be necessary to operate the envelope (e.g., collapse).Alternate to a valve, the delivery apparatus can be twisted (or rotated)once the filling is completed and this twisting crimps and seals theneck of the implant.

In certain embodiments, the flow control member in its resting conditionmay be configured to define at least one withdrawal opening and in itsnon resting condition may be configured to allow less viscous fluids toflow in at least two directions and more viscous fluids to flow in atleast one direction. Less viscous materials are those materials thatrequire less energy to flow. Less viscous fluids include, but notlimited to, air, water, certain oils. (The term “less viscous” can beseen as a relative term where it defines a material which is lessviscous than the material being introduced into the envelope as thebiomaterial, or less viscous than the material which is limited to flowin at least one direction by the flow control member.)

In certain embodiments, the flow control member in its first conditionmay be configured to define at least one withdrawal opening and in itssecond condition may be configured to allow less viscous fluids to flowin at least two directions and more viscous fluids to flow in onedirection.

In some aspects, other flow control mechanisms or means for flow controlmay be used. For example star valves, multi cuspid valves, umbrellavalves. In some aspects, other flow control mechanisms may be used aslong as that mechanism controls the flow of certain fluids in at leastone direction. In certain aspects, the flow control mechanism may beconfigured to allow less viscous fluids to flow in at least twodirections and more viscous fluids to flow in at least one direction.For example, using certain flow control mechanisms fluids such as gas,water, solutions or combinations thereof, will be permitted tosubstantially flow in at least two directions through the flow controlmechanism and viscous filler material will be permitted to substantiallyflow through the control mechanism into the envelope.

In certain aspects, the means for flow control may be configured toallow less viscous fluids to flow in either direction or more viscousfluids to flow in at least one direction.

In certain embodiments, the flow control member may be configured toallow less viscous filler material to flow into the envelope where thefiller material becomes more viscous, thereby preventing it from flowingback through the flow control member.

One advantage of certain flow control members disclosed herein is thatthey may be configured to permit viscous materials to flow in onedirection allowing the carrier tube to be detached after the viscousmaterial has been delivered to the envelope. Thus permitting shortersurgery times and anaesthesia for the patient, resulting in a fasterrecovery and less chance of complications.

The second assembly may comprise a filler tube received through thefirst assembly to communicate with the interior of the envelope and afiller material dispenser mountable to a proximal end of the fillertube. The dispenser assembly may feed into a static mixer, a distal endof the static mixer carrying the attachment device, the arrangementbeing such that, when the second assembly is fast with the firstassembly and the withdrawing device is attached to the first assembly, asecond closed system is created which enables fluid to be withdrawn fromthe interior of the envelope by the withdrawing device to create a lowpressure region in the envelope. A “low” pressure may be defined as apressure below ambient pressure.

Whether the filler material is a single part, two part, etc, it can bepremixed and delivered through the filler tube rather than having to gothrough a static mixer. Alternatively, the mixing can be through adynamic mixer. Also, the in situ curing filler material usually relieson a catalyst and or cross-linker. That molecule required to initiatethe chemical reaction can be added into the mixture by having it coatedon the surfaces the filler material is in contact with. This includesbut is not limited to, the static mixer, inner lining or filler tube,inner lining of envelope etc.

The dispenser may contain filler material, the filler materialpreferably being of the same class or type of material as the materialof the envelope so that, when the envelope has been charged with thefiller material and the filler material has been allowed to set, atissue prosthesis is formed which is elastically deformable. Theenvelope is filled with the filler material initially up until theenvelope reaches its relaxed configuration (i.e., its premolded form).Then, when the filling continues, it undergoes elastic deformation forup to 10 times its relaxed volume, or for up to 3, 4, 5, 6, 7, 8, or 9times its relaxed volume or until it fills to conform substantially tothe cavity of the nucleus where the substantiality of the fill is notlimited by the limitations of the apparatus.

In certain embodiments, the envelope may be resilient and elasticallydeformable. The in situ curing material may also be resilient andelastically deformable. When the systems combine, they form a resilientand elastically deformable implant. When the envelope and in situmaterial combine, they take on the properties substantially similar tothat of the envelope, or to that of the in situ curing material, or thecombined system may take on completely different mechanical properties(possibly due to the fact that when they combine, they undergo achemical reaction which changed the properties altogether). By“elastically deformable” it is meant that the prosthesis can be deformedby the application of a force and, upon removal of the force, the tissueprosthesis substantially returns to its undeformed state. In certainembodiments, the filler material may be of a different class or typethan the material of the envelope. For example, but not limited to, apolyurethane envelope filled with a silicone filler material, a siliconeenvelope with a polyurethane filler material, a polyester envelopefilled with a silicone filler, polyester envelope filled withpolyurethane, or other combinations of acceptable filler material andacceptable envelope material. Further, the envelope may be apolyethylene envelope filled with either a polyurethane or a siliconefiller. Combinations of the materials also apply. For example, thefiller may be a combination of silicone and polyurethane.

The system may include an obturating device receivable in one of thetubes of the first assembly for tamping a part of the tissue prosthesisinto position after formation of the tissue prosthesis. The obturatingdevice may carry a locking member at its proximal end for locking to aworking cannula of the system so that, after tamping of the part of thetissue prosthesis, the working cannula and the obturator can be removedsimultaneously.

In certain embodiments, there may be provided a tissue prosthesisinsertion system which includes an assembly comprising a plurality ofnested tubes, one of which is a carrier tube for carrying a component ofa tissue prosthesis at its distal end and another of which is a fillertube received with clearance in the carrier tube to define a passagebetween the filler tube and the carrier tube, the proximal end of thefiller tube and the proximal end of the carrier tube being in sealingengagement; and a withdrawing device attachable to the assembly so that,when the withdrawing device is attached and the component of the tissueprosthesis is mounted on the distal end of the carrier tube, a closedsystem is formed which allows the withdrawing device to be used toincrease the volume of the closed system to form a low pressure regionat least in the component.

The assembly may comprise a stiffening member received in the carriertube, a proximal end of the stiffening member and a proximal end of theassembly carrying complementary engaging formations for enabling thestiffening member to engage sealingly with at least one of the pluralityof nested tubes to create an initial closed system, operation of thewithdrawing device forming a low pressure region in the interior of thecomponent, in use, to cause the component to collapse around thestiffening member. The system may include a filler tube insertable intothe carrier tube after removal of the stiffening member to contribute tothe formation of a further closed system which is then acted on by thewithdrawing device to increase the volume of the closed system to reducethe pressure in the interior of the component.

The withdrawing device may be operable to test the integrity of thesystem to ensure that there are no leaks in the system.

In certain embodiments, there may be provided a tissue prosthesisinsertion system which includes a working cannula for accessing a sitein a patient's body percutaneously and/or minimally invasive manner forcarrying out a tissue prosthesis insertion procedure at the site; and anobturating device receivable in the cannula for tamping a part of atissue prosthesis into position after formation of the tissueprosthesis.

The obturating device may comprise a blunt-ended rod slidably receivablein the working cannula.

In certain embodiments, there may be provided a tissue prosthesiscomponent which includes an envelope of an elastically deformablematerial, the envelope defining an access opening; and a flow controlmember arranged in the access opening, the flow control member beingconfigured to permit withdrawal of fluid from an interior of theenvelope prior to filling the envelope with a filler material.

The flow control member may be a flow control valve which, in a restcondition, defines a withdrawal opening to allow the passage of certainfluids in both directions. The envelope may have a neck portion, theneck portion defining the access opening and the flow control memberbeing arranged within the neck portion.

In certain embodiments, there may be provided methods of preparing afirst assembly of a tissue prosthesis system for insertion into apatient's body, the methods comprising providing the first assemblywhich comprises a plurality of nested tubes, one of the tubes being acarrier tube; mounting a component of the prosthesis on a distal end ofthe carrier tube, the component being of an elastically deformablematerial; inserting a stiffening member into the first assembly so thatthe stiffening member extends into an interior of the component andcausing a proximal end of the stiffening member to sealingly engage aproximal end of the first assembly; attaching a withdrawing device tothe first assembly so that the withdrawing device is in fluidcommunication with the interior of the component; and operating thewithdrawing device to reduce the pressure in the interior of thecomponent to cause the component to collapse about the stiffeningmember.

The methods may include attaching the withdrawing device to a fluid portof the first assembly in a sealing manner. The withdrawing device may bea syringe which is attached by a Luer lock mechanism to the fluid portof the first assembly.

After the component has been collapsed about the stiffening member, themethods may include placing a protective sheath about the component.More particularly, the methods may include placing the protective sheathabout the component by sliding the protective sheath over the component,the protective sheath constituting one of the tubes of the nested tubesof the first assembly. Further, the methods may include treating one ofthe protective sheath and the component with a lubricating medium tofacilitate relative displacement between the protective sheath and thecomponent.

The methods may include using the withdrawing device to test theintegrity of the combination of the first assembly and the component andthe stiffening member attached to the first assembly.

In certain embodiments, there may be provided methods of forming atissue prosthesis at a site in a patient's body, the methods includingproviding a first assembly comprising a plurality of nested tubes, oneof the tubes being a carrier tube with a component of the prosthesiscarried at a distal end of the carrier tube: inserting the firstassembly into a cannula placed in the patient's body; magneticallyattaching a second assembly to a proximal end of the first assembly; andcharging a filler material from the second assembly into the componentand allowing the filler material to set.

The methods may include, initially, preparing the first assembly asdescribed above.

The methods may include, once the distal end of the first assembly is atthe desired location at the site in the patient's body, withdrawing theprotective sheath to expose the component, the component being anenvelope of an elastically deformable material. Further, the methods mayinclude using the withdrawing device to test the integrity of the firstassembly either after or before withdrawing the protective sheath.

The methods may include removing the stiffening rod prior tomagnetically attaching the second assembly to the first assembly.Further, the methods may include causing the second assembly to engagesealingly with the first assembly so that, together with the componentand the withdrawing device, a closed system is formed.

After the second assembly has been attached to the first assembly, themethods may include operating the withdrawing device to create a lowpressure in the component. Further, the methods may include using thewithdrawing device to test the integrity of the system comprising thetwo assemblies and the component attached to the first assembly.

The methods may include dispensing the filler material from a dispenserof the second assembly. Preferably, the methods include purging fillermaterial from the dispenser prior to attaching the dispenser to a staticmixer constituting a part of the second assembly. The methods mayinclude, during filling of the component via a filler tube extendingfrom the static mixer, operating the withdrawing device at least tomaintain, or increase, the volume of the closed system.

The methods may include after filling the component, detaching thecarrier tube from the tissue prosthesis formed by the combination of thecomponent and the filler material contained in the component. Thecarrier tube may be detached prior to the filler material having curedor set or after the filler material has at least partially set. Themethods may include detaching the carrier tube from the tissueprosthesis when the required pressure has been reached in the component.In the case of intervertebral disc nucleus prosthesis, the requiredpressure may be that which inhibits distraction of the disc.

In certain embodiments, the methods may include detaching the tissueprosthesis by relative axial motion between the carrier tube and adisplacement device of the first assembly. The displacement device maybe a further tube arranged about the carrier tube and the relative axialmotion may be effected and affected by withdrawing the carrier tuberelative to the displacement device. In other embodiments, the methodsmay include detaching the tissue prosthesis by filling the componentwith filler material to the extent that the component is released fromthe carrier tube. In further embodiments, the methods may includedetaching the tissue prosthesis by manipulating the carrier tuberelative to the component to cause separation of a part of the componentattached to the carrier tube from a remainder of the component, theseparation occurring at a zone of weakness in the component. Themanipulation may involve rotating the carrier tube with respect to thecomponent.

The methods may include, after formation of the tissue prosthesis,tamping a part of the tissue prosthesis into position. If necessary ordesirable, the methods may include, before placing the component inposition at the site, preparing the site. The methods may includepreparing the site by removing degenerative tissue from the site priorto placing the component at the site.

In certain embodiments, there may be provided equipment for forming atissue prosthesis in situ at a site in a patient's body, the equipmentcomprising a delivery device displaceably receivable in a lumen of anintroducer, the delivery device defining a passageway; an envelopecarried at a distal end of the delivery device, the envelope being of abiologically inert, elastically deformable material capable of beingexpanded to conform to an interior surface of a cavity formed at thesite; and a supply of a filler material chargeable in a fluent stateinto the envelope through the passageway of the delivery device, thefiller material being of the same class of material as the envelope toform, when cured, together with the envelope, a unified prosthesis.

The equipment may include an aperture forming element to form anaperture into the site, the aperture forming element being receivablethrough the introducer for delivery to the site. The aperture formingelement may, for example, be a trocar.

Further, the equipment may include a tissue removal mechanism insertablethrough the aperture for removing tissue, if required, to form thecavity. The tissue removal mechanism may comprise mechanical,ultrasonic, laser, Argon gas or radio frequency ablation mechanisms, orthe like in combination with suction and irrigation. For example, thetissue removal mechanism may be a reaming-type tool.

The equipment may include a dispenser containing the supply of fillermaterial. Further, the equipment may include a sensing arrangementconfigured to sense a parameter of the filler material charged into theenvelope. The sensing arrangement may comprise a pressure sensor forsensing the pressure of filler material charged into the envelope, atemperature sensor for sensing the temperature of the filler materialcharged into the envelope, be configured to sense the quantity of fillermaterial charged into the envelope and/or comprise a flow rate sensorfor sensing the rate of flow of the filler material into the envelope.Further, the sensing arrangement may be configured to sense the presenceof air bubbles in the filler material charged into the envelope.

In certain embodiments, there may be provided equipment for forming atissue prosthesis in situ at a site in a patient's body, the equipmentcomprising a tubular delivery device, the delivery device defining apassageway, an envelope of the prosthesis being mountable to a distalend of the delivery device to be received in a cavity at the site; afiller member receivable in the passageway of the delivery device, thefiller member being receivable with clearance in the passageway todefine a gap to enable fluid to be manipulated or evacuated at leastfrom the envelope, at least prior to the filler material being chargedinto the envelope; and a removal mechanism carried by the deliverydevice for enabling the envelope to be removed from the delivery deviceafter the envelope has been charged with filler material via the fillermember.

The equipment may include a tubular introducer and an aperture formingelement, such as a trocar, to form an aperture at the site, the apertureforming element being receivable through the introducer for delivery tothe site.

Further, the equipment may include a tissue removal mechanism insertablethrough the aperture for removing tissue, if required, to form thecavity.

The introducer and the delivery device may include a retainingarrangement for retaining the delivery device with respect to theintroducer.

In addition the equipment may include a supply of filler materialattachable to a proximal end of the filler member. The filler materialmay be a mixture of a plurality of parts and the supply of fillermaterial may comprise a dispenser defining a plurality of chambers ineach of which one part of the filler material is received prior to use.The dispenser may further comprise a mixer arranged intermediate anoutlet of the dispenser and the proximal end of the filler member formixing the filler material prior to charging it into the envelope.

A proximal end of the delivery device may carry a connector forconnection to an evacuating mechanism such as an evacuation pump.

The equipment may include the envelope, the envelope being of anelastomeric material capable of expanding to up to about 3, 4, 5, 10,40, 50, 100, or 150 times its relaxed state. Preferably, the envelope isexpanded to be stretched and retained under tension after being chargedwith the filler material. The envelope may include a neck portion, theneck portion defining a zone of weakness for facilitating separation ofthe envelope from the delivery device.

FIGS. 25-28, illustrate an exemplary assembly of a tissue prosthesisinsertion system designated generally by the reference numeral 10. Theassembly 10 comprises a plurality of nested tubes 12. As shown in FIG.28, the set of nested tubes 12 comprises an inner, carrier tube 14 onwhich a component, in the form of an envelope. 16 of a tissue prosthesisis mounted, the component 16 being mounted on a distal end of thecarrier tube 14. The carrier tube 14 is received within a push-off tube18 which is used for removing the envelope 16, after filling, from thecarrier tube 14 as will be described in greater detail below.

The nested tubes 12 further include a protective sheath 20, arrangedabout the push-off tube 18. As illustrated in FIGS. 26 and 28, theprotective sheath 20 is of a length to cover the envelope 16, the sheath20 projecting beyond a distal end of the envelope 16 when in itsoperative, protective position. It is to be noted that the nested tubes12 are shown, in use, mounted in a working cannula 22 used for insertingthe first assembly 10 percutaneously to deliver the envelope 16 into asite at a patients body in which the prosthesis is to be formed. Thenested tubes 12 are all of a metal material such as a steel materialwhich is bio-compatible.

The first assembly 10 further includes a stiffening member in the formof a stiffening rod 24. The stiffening rod 24 is of a length to projectfrom a proximal end of the first assembly 10 through a lumen 26 (FIG.28) of the carrier tube 14 to be received in an interior 28 of theenvelope 16.

A collar assembly 30 is arranged at a proximal end of the nested tubes12. The collar assembly 30 comprises a first collar 32 secured to aproximal end of the cannula 22. The cannula 22 has a pair ofdiametrically opposed, longitudinally extending slits, one of which isshown at 34 in FIG. 25 of the drawings, arranged distally of the collar32. The protective sheath 20 is slidably arranged relative to thecannula 22 and has a pair of opposed, radially outwardly extending tabs38 arranged at its proximal end. The tabs 38 project through the slits34 in the cannula 22 to enable a clinician to manipulate the protectivesheath 20.

The push-off tube 18 has a collar 36 arranged at its proximal end, thecollar 36 being connected to the collar 32 of the cannula 22 via abayonet fitting. The carrier tube 14 carries a Y-connector 42 at itsproximal end, the Y-connector 42 extending from a collar 40. The collar40 attaches to the collar 36 of the push-off tube 18. The Y-connector 42carriers a magnetic mount 44 at its proximal end. The magnetic mount 44carries a plurality of annular magnets 46. These magnets 46 are rareearth magnets and are covered by a cover member 48.

The Y-connector 42 further includes a branch limb 50 defining aconnection port 52 for a withdrawing device. The connection port 52 isin communication with a passage (not shown) defined between the carriertube 14 and, initially, the stiffening rod 24. The stiffening rod 24carries a securing formation in the form of a mount 54 at its proximalend. A distal part 56 of the mount 54 is tapered and engages a taperedsocket 58 defined by the magnetic mount 44 in a sealing or closingmanner so that, once a withdrawing device has been attached to the port52, a closed system is formed.

More particularly, once the envelope 16 has been attached to the distalend of the carrier tube 14, the stiffening rod 24 is inserted throughthe lumen 26 of the carrier tube 14 to be received in the interior 28 ofthe envelope 16. When the distal end of the stiffening rod 24 isreceived in the envelope 16, the distal part 56 of the mount 54 of thestiffening rod 24 sealingly engages with the socket 58 in the magneticmount 44 of the Y-connector 42 to form a substantial seal, or a hermeticseal.

A withdrawing device in the form of a syringe 62 (FIG. 30) is connectedvia a Luer fitting 64 to the port 52 of the Y-connector 42 to form aclosed system. A plunger 66 of the syringe 62 is drawn in the directionof arrow 68. This increases the volume of the closed system, reducingthe pressure in the interior 28 of the envelope 16 and causing theenvelope 16 to collapse about the distal end of the stiffening rod 24.

The tabs 38 of the protective sheath 20 are gripped by an operatorassembling the first assembly 10 and are urged in the direction of arrow70 (FIG. 26) to cause the protective sheath 20 to slide over and protectthe envelope 16. To facilitate sliding movement between the protectivesheath 20 and the envelope 16, a distal end of the first assembly 10 canbe immersed in a suitable lubricating medium such as, for example,water. In this regard it should be noted that the envelope 16 is made ofsilicone material rendering it hydrophobic. Thus, the water acts as alubricant and enables the protective sheath 20 to be slid over theenvelope 16. Instead of immersing the distal end of the first assembly10 in the lubricating medium, an internal surface of the protectivesheath 20 could, optionally, be coated with a lubricating medium of ahygroscopic or hydrophilic material such as a hydrogel. Alternatively,rather than treating the inner surface of the protective sheath, theprotective sheath itself may be made from lubricious materials whichinclude, but not limited to, polytetrafluoroethylene (Teflon), acetal,polypropylene, polyethylene. All of the above mentioned materials mayalso be a treatment option for the inner lining of the protectivesheath. Further, should the protective sheath be made from the describedpolymers, they may also be treated to improve the lubricity.

After retracting the sheath 20 in the direction opposite to that ofarrow 70, the integrity of the first assembly 10 is tested for leaks byfurther withdrawing the plunger 66 of the syringe 62 in the direction ofarrow 68. If the plunger 66 does not return to its previous position,this is an indication that there is a leak in the first assembly 10 andremedial action can be taken to locate the leak. Conversely, should theplunger 66 return to its previous position, this is an indication thatthe integrity of the first assembly 10 is intact and the procedure canproceed.

Instead of pulling on the plunger 66 of the syringe 62, testing of theintegrity of the first assembly 10 could involve pushing on the plunger66 of the syringe 62 and then releasing the plunger 66. If the plunger66 does not return to its original position that is an indication thatthere is a leak in the system such as may occur if the envelope 16 istorn.

FIGS. 29-32, show a tissue prosthesis insertion system which isdesignated generally by the reference numeral 80. The system 80 includesthe first assembly 10 and a second assembly 82. The second assembly 82comprises a filler tube 84 including a static mixer 86 at a proximal endof the filler tube 84. The static mixer 86 is secured to a distal end ofa filler material dispenser 88. The filler material dispenser 88 has ascrew-threaded attachment 89 for engaging a screw-threaded boss 90 at aproximal end of the static mixer 86. A distal end of the static mixer 86carries an attachment device in the form of a second magnetic mount 92.As illustrated in FIG. 31, the magnetic mount 92 comprises a pair ofannular rare earth magnets 94 closed off by a cover 96. The mount 92also includes a tapered fitting 98. The tapered fitting 98 of the mount92 and the tapered socket 58 of the mount 44 define complementaryengaging formations. Thus, the tapered fitting 98 is received within thesocket 58 of the magnetic mount 44 of the Y-connector 42 in ahermetically sealing manner, the fitting 98 and the socket 58constituting a Luer slip fitting. Thus, once again, once the syringe 62has been attached to the port 52 of the Y-connector 42, a closed systemis formed.

The benefit of magnetically attaching the second assembly 82 to thefirst assembly 10 is that the requirement for relative rotation betweenthe two assemblies 10 and 82 for attachment to each other is obviated.This also enables the cannula 22 of the first assembly 10 moreaccurately to be retained in position, in use. It also maintains theengagement of the two assemblies 10 and 82 during filling of theenvelope 16. The filler material used for forming the tissue prosthesisis a silicone rubber material. To inhibit curing of the filler materialprior to its being charged into the envelope 16, the filler material isretained in two, separate parts. For this purpose, the dispenser 88includes two separate reservoirs 100, in each of which one part of thefiller material is initially received. Each reservoir 100 has a plunger(not shown) associated with it for dispensing the parts of the fillermaterial simultaneously from the reservoirs 100 into the static mixer 86where the parts are mixed prior to being charged into the filler tube 84to be injected into the interior 28 of the envelope 16. The plungers aredisplaceable together with each other via a suitable displacing device(also not shown), for example, a pneumatic gun.

After removal of the stiffening rod 24, the second assembly 82 isattached to the first assembly 10 via the magnetic mounts 44 and 92.More particularly, the part of the second assembly 82 comprising thestatic mixer 86 with the filler tube 84 projecting from the static mixer86 is magnetically attached to the first assembly 10 via the magneticmounts 44 and 92 with the fitting 98 sealingly engaging in the socket58. Prior to attaching the dispenser 88 to the static mixer 86, fillermaterial is purged from the reservoirs 100 by urging the plungerstowards the threaded end 89 of the dispenser 88 to expel a portion offiller material from the reservoirs 100 to ensure that the correct ratioof the two parts of the filler material is dispensed. The dispenser 88is then attached to the static mixer 86.

The pressure in the interior 28 of the envelope 16 is again lowered bywithdrawing the plunger 66 of the syringe 62 in the direction of arrows68. This serves to collapse the envelope 16 prior to the filler materialbeing charged via the filler tube 84 into the interior 28 of theenvelope 16. To enable the pressure in the interior 28 of the envelope16 to be lowered, the filler tube 84 is a loose fit within the carriertube 14 to create an annular passage 102 (FIG. 32) via which air, gas orcertain other fluids can be withdrawn from the interior 28 of theenvelope 16 by the syringe 62.

After lowering the pressure in the interior of the envelope 16, theintegrity of the system 80 is again checked by further attempting towithdraw the plunger 66 from the syringe 62 in the direction of thearrows 68. Should the plunger 66 remain in its withdrawn position, thisis an indication that there is a leak in the system and remedial actioncan be taken to locate the leak. Conversely, should the plunger 66return to its previous position, this is an indication that theintegrity of the system 80 is intact and the clinician can proceed. Onceagain, instead of pulling the plunger 66, testing could involve pushingthe plunger 66 and determining whether or not it returns to its originalposition. If not, that is an indication that there is a leak in thesystem 80 and remedial action can be taken to locate the leak.

Referring generally to FIGS. 33-37, to insert the nucleus prosthesisinto the disc, an incision in made in the patient's skin and anannulotomy is performed on the annulus 126 of the disc 124 in aminimally invasive manner to form an opening 132. This enables access tobe gained to the interior of the disc 124. To perform the annulotomy,the cannula 22 is inserted through the incision until a distal endsabuts the annulus 126. An annulotomy performing tool, such as a trocaror a guide wire plus dilator (not shown), is inserted through thecannula 22 and pierces the annulus 126 to enable access to be gained tothe nuclear material of the disc 124. If necessary, a nucleotomy isperformed to remove the nuclear material. However, in certaincircumstances, the degenerative process may have dehydrated, extruded orshrunken the nuclear material so that a cavity has already been formedand the necessity to perform the nucleotomy is obviated.

Whether or not a nucleotomy is performed, once the cavity in the disc124 is present, the first assembly 10 is inserted into the cannula 22.As indicated above, the first assembly 10 comprises the carrier tube 14with the envelope 16 mounted on a distal end of the carrier tube 14, thepush-off tube 18 and the protective sheath 20, with the protectivesheath 20 extending over the envelope 16.

Once the envelope 16 is in position within the disc 124, the protectivesheath 20 is withdrawn by urging the tabs 38 of the protective sheath 20in the direction opposite to that of the arrow 70, the tabs 38 beingreceived within recesses 104 of the collar 32 of the cannula 22.

The assembly 10 is locked in position relative to the working cannula 22by the bayonet fitting of the collar 36 of the push-off tube 18 engagingthe collar 32 of the cannula 22.

The stiffening rod 24 is removed and the second assembly 82 is attachedto the first assembly 10, as previously described. Some filler materialis purged from the reservoirs 100 of the dispenser 88 and the dispenser88 is then attached to the proximal end of the static mixer 86. Thisre-forms the closed system enabling air to be removed from the envelope16 by operating the syringe 62 and pulling its plunger 66 in thedirection of arrows 68.

The plungers of the dispenser 88 are then urged towards the distal endof the dispenser 88 to discharge material from the reservoirs 100. Theparts of the filler material discharged from the reservoir 100 are mixedtogether in the static mixer 86 before being fed into the filler tube84. The plunger 66 of the syringe 62 is continued to be withdrawn in thedirection of arrow 68 during passage of the filler material along thefiller tube 84 at least to maintain or to increase the volume of theclosed system to remove air from the envelope 16 as the filler materialis charged into the envelope 16. The filler material 84 is conveyedthrough the filler tube 84 into the interior 28 of the envelope 16through a tissue prosthesis component in the form of a filler valve 106.The filler valve 106 will be described in greater detail below.

As the filler material enters the interior 28 of the envelope 16, itcauses the envelope 16 to expand to conform to the shape of the cavitywithin the intervertebral disc. It will be appreciated that, due to theresilient flexibility of the envelope 16, the envelope 16 will readilyconform to the shape of the cavity and the envelope 16 need not be ofany particular pre-configured dimensions.

FIGS. 33-35, illustrate the tissue prosthesis component in the form ofthe filler valve 106 of the envelope 16 is described in greater detail.It is to be noted that the envelope 16 has a bulbous body portion 108(FIG. 32) integrally formed with a neck portion 110. The envelope 16 isattached to the distal end of the carrier tube 14 via the neck portion110. The valve 106 is received within the neck portion 110 of theenvelope 16. The valve 106 is a duck bill valve having a pair of opposedoperating members or operating flaps 112. The operating flaps 112, whenin their rest condition, as shown in FIGS. 33-35 of the drawings, do notclose fully and a slit 114 is defined between the operating flaps 112 ofthe valve 106. This is desirable so that, prior to filler material beingcharged into the interior 28 of the envelope 16, air can be withdrawnfrom the interior 28 of the envelope 16 via the slit 114 using thesyringe 62.

Once the filler material has filled the interior 28 of the envelope 16,it occludes the slit 114 or, instead, presses down on the operatingflaps 112 to cause them to deform to close the slit 114. Also, thefiller material could have sufficient viscosity to inhibit extrusion ofthe filler material outwardly through the slit 114. It will beappreciated that, once the filler material has set, it no longer matterswhether or not the slit 114 is fully closed.

To inhibit overfilling of the envelope 16, the envelope is mounted onthe carrier tube 14 such that as the envelope 16 fills with fillermaterial, any excess filler material will “extrude” between the neckportion 110 of the envelope 16 and the carrier tube 14 causing theenvelope 16 to be released from the carrier tube 14.

After the desired quantity of filler material has been charged into theenvelope 16, the second assembly 82 is detached from the first assembly10 by breaking the magnetic bond between the magnetic mounts 44 and 92.The filler tube 84 is withdrawn from the interior of the carrier tube14.

The envelope 16 is detached from the carrier tube 14 by relativedisplacement between the carrier tube 14 and the push-off tube 18. Moreparticularly, the carrier tube 14 is withdrawn from the push-off tube 18by detaching the collar 40 of the Y-connector 42 from the collar 36 ofthe push-off tube 18 and withdrawing the carrier tube 14. This causesthe proximal end of the neck portion 110 of the envelope 16 to come intoabutment with the distal end of the push-off tube 18 causing detachmentof the envelope 16 from the carrier tube 14. The push-off tube 18 isthen removed. The tissue prosthesis 134 (FIGS. 36 and 37), comprisingthe envelope 16 filled with the filler material, is retained in positionwithin the intervertebral disc 124 of the patient. Additional methodsfor removing the envelope may include, for example, an external orinternal cutting mechanism on the tubes which can sever the implant fromthe delivery apparatus, means of twisting and crimping the neck of theimplant (in certain embodiments, this may both seal and detach theimplant, and if the means in which the envelope is held onto the carriertube is purely an interference fit or just tight fit, then pulling onthe carrier tube can result in detachment of the envelope (the tube canalso be rotated to detach).

As shown in FIGS. 36 and 37, after removal of the carrier tube 14, atleast a part of the neck portion 110 of the envelope 16 may protrudethrough the annulus 126 of the intervertebral disc 124. In addition aresidue of filler material may be present in the distal end of theworking cannula 22. Therefore, prior to removal of the working cannula22, an obturator 136 is inserted into a lumen 138 of the cannula 22. Theobturator 136 comprises a blunt-ended rod 140 which is a tight fitwithin the lumen 138 of the cannula 22.

The obturator 136 is used to urge any residue of filler material intothe disc cavity and to tamp the part of the neck portion 110 of theenvelope 16 into the disc cavity, as shown in FIG. 37. The prosthesis134 is thus entirely contained within the disc cavity 134 with minimal,if any, protrusion into the annulus 126 of the disc 124.

The obturator 136 can, if desired, be locked to the working cannula 22by an attachment collar 142 carried at a proximal end of the obturator136 locking to the collar 32 of the working cannula 22 in a bayonetfitting manner. This allows the obturator 136 to be retained in positionduring setting of the filler material and inhibits extrusion of fillermaterial from the envelope 16 and/or from the disc cavity. Aftercompletion of the tamping and setting process, the working cannula 22and the obturator 136 are removed.

Tamping the neck portion 110 of the envelope 16 into the disc cavity 122inhibits prosthesis expulsion and excessive loading on the aperture 132in the annulus 126 of the disc 124. In addition, the fact that there isno remnant of the envelope 16 in the annulus 124 enhances closure of theaperture 132 in the annulus 124.

It is an advantage of this (and other embodiments) that a tissueprosthesis insertion system is provided which is simple to operate by aclinician. The assemblies are easily connected together using themagnetic connection which improves the stability of the device andobviates the need for relative rotation of the assemblies relative toone another to connect them together. In addition, the use of theprotective sheath protects the envelope against damage while it is beinginserted into and positioned in the patient's body. The sheath isrelatively simple to operate by the clinician thereby improving theperformance of the system as a whole. Further, the use of the syringe asa low pressure generating device simplifies the system and precludes theneed for complicated pumps, etc. Also, due to the fact that the syringeprovides a closed system, it is not necessary to continuously withdrawgas out of the envelope while it is being charged with filler material.This further simplifies operation of the system.

Referring to FIGS. 38 and 39, reference numeral 10 generally designatesanother exemplary embodiment of a prosthesis delivery system. Theprosthesis delivery system 10 includes a plurality of nested tubes 12shown in FIG. 39. In some embodiments, the nested tube will be 3, 4, 5,or 6. An outermost tube 14 of the nested tubes 12 functions as a cannulain which the remaining tubes are received. The remaining tubes form partof a prosthesis delivery apparatus 16. The tubes of the nested tubes 12have a flared wall portion 18. The flared wall portion 18 of the nestedtubes mates 12 with a tapered end 20 of a static mixer 22 of adispensing arrangement 24 of the apparatus 16 of the system 10.

The cannula 14 further includes a manipulating arrangement 26, arrangedat a proximal end of the cannula 14, for connecting and effectingmanipulation of the nested tubes 12.

A first tube 14 of the nested tubes is the cannula which is used forinsertion of the prosthesis delivery apparatus 16 percutaneously to asite in which a prosthesis is to be inserted.

The system 10 is intended for use in the insertion of an intervertebraldisc nucleus prosthesis in position in a disc after performance of anucleotomy, if necessary, on a disc to remove the natural nucleus of thedisc. The nucleus may have herniated through an annulus of the disc dueto degeneration of the disc. In such circumstance, it may not benecessary to perform a nucleotomy on the disc.

The prosthesis includes an envelope 28. The envelope 28 is carried onthe end of a carrier tube 30. The envelope 28 is an expansible envelopeof an elastically deformable material which is charged with a fillermaterial to fill a cavity of the disc left by removal of the naturalnucleus. Typically, the envelope is of a silicone material which iscapable of expanding up to 1000% its relaxed state without plasticallydeforming. The filler material used with the envelope 28 is also of asilicone material and is dispensed from a dispenser 32 of the dispensingarrangement 24. The filler material is charged into the envelope 28, inuse, through a filler tube 34. The filler tube 34 is nested within thecarrier tube 30.

A further tube 36 is arranged outwardly of the carrier tube 30 and isused to push off the envelope 28 from the carrier tube 30 after beingfilled with the filler material and the filler material has at leastpartially set or cured.

It will be noted that, in this embodiment, each of the tubes 14, 30, 34and 36 has the flared portion 18 so that all the tubes mate with thetapered end 20 of the static mixer 22 of the dispensing arrangement 24.Further, a proximal portion of the nested tubes 12 projects proximallyof the tapered end 20 of the static mixer 22 to surround the staticmixer 22 as shown in FIG. 38. The tubes 14, 30, 34 and 36 are lockedtogether once nested. Further, the tubes 30 and 34 may seal hermeticallyonce nested and locked together.

The manipulating arrangement 26 of the cannula 14 includes a rupturingmechanism for rupturing the cannula after placement of a distal end ofthe prosthesis delivery apparatus 16. The rupturing arrangementcomprises at least a pair of opposed longitudinally extending lines ofweakness, one of which is shown at 38 in FIG. 39. The other line ofweakness is diametrically opposed to the shown line of weakness 38. Thelines of weakness 38 divide the cannula into two shells 40 and 42. Themanipulating arrangement 26 comprises a pair of opposed tabs 44. Eachtab 44 is integrally formed with one of the shells 40, 42 of the cannula14. The tabs 44 are used for connecting the nested tubes 12 to thecannula 14. Also, by pulling radially on the tabs 44, the cannula 14ruptures along the lines of weakness 38 facilitating withdrawal of thecannula 14 from the prosthesis delivery apparatus 16.

A gap 46 (FIG. 39) is defined between the carrier tube 30 and the fillertube 34. The gap 46 communicates with a port 48 (FIG. 38) and with theinterior of the envelope 28. The port 48, in use, forms part of a boss50 and an evacuation apparatus (not shown) is connected to the port 48to enable the interior of the envelope 28 to be evacuated either priorto or as the filler material is charged into the envelope 28.

The silicone used for expanding the envelope 28 is of the type which,prior to use, is maintained in two separate parts. Thus, the dispenser32 has at least two compartments 52, in each of which one part of thesilicone material is stored, prior to being fed through the static mixer22, where mixing of the parts takes place, and being charged into theenvelope 28.

In use, an incision is formed in the skin of the patient. The cannula14, with a trocar (not shown) contained in a lumen of the cannula 14, isinserted through the incision to the disc on which the operation is tobe performed. The trocar is used to perform an annulotomy on an annulusof the disc. Once that operation has been completed, the trocar iswithdrawn. A device (not shown) is inserted through the cannula 14 toperform the nucleotomy, if necessary. The device could, for example, bea mechanical device such as a reamer to ream the degenerative nuclearmaterial from the intervertebral disc.

After completion of the nucleotomy, the device is withdrawn. Theprosthesis delivery apparatus 16 is then inserted into the lumen of thecannula 14 and the envelope 28 is inserted through the annulotomyaperture into the cavity of the disc formed as a result of thenucleotomy. The filler material is dispensed from the dispenser 32,through the static mixer 22 and the filler tube 34 into the interior ofthe envelope 28 while, simulataneously, a suction is maintained on theport 48 and the gap 46.

In an embodiment, the cannula 14 is then removed by rupturing it alongthe lines of weakness 38 by pulling radially outwardly on the tabs 44.

Once this has occurred, the push off tube 36 is free to be manipulatedrelative to the carrier tube 30 by being urged in a direction of arrow54 (FIG. 39) by means of a manipulating ring 56 carried at a proximalend of the push off tube 36. Pushing off the envelope 28 from thecarrier tube 30 allows the prosthesis delivery apparatus 16 to bewithdrawn from the patient's body.

In another embodiment, the cannula 14 remains in place. The envelope 28is pushed off from the carrier tube 30 by withdrawing the carrier tube30 relative to the push off tube 36 in a direction opposite to the arrow54. The cannula 14 is the final item to be removed with the remainingnested tubes 12 still contained in and attached to the cannula 14.

FIGS. 40-42, illustrates certain embodiments of a prosthesis deliverysystem 10, in this embodiment, the system 10 includes a furthercomponent in the form of a cover tube 60 (FIG. 40). The cover tube 60constitutes a sheath and, at least initially, protects the envelope 28of the prosthesis when it is inserted into the cannula 14.

For this purpose, a distal end of the cover tube 60 is slotted, as shownby slots 62. In these embodiments, two slots 62 are provided to define apair of opposed resiliently flexible leaves 64. The leaves 64 are ableto be displaced outwardly in the direction of arrows 66. Thus, in use,the cover tube 60, which has substantially the same length as thecannula 14, is placed over the prosthesis delivery apparatus 16 so thatthe envelope 28 is received between the leaves 66 at the distal end ofthe cover tube 60. The entire prosthesis delivery apparatus 16,including the cover tube 60, is then inserted into the cannula 14 andthe distal end of the cover tube 60 protects the envelope 28.

The cover tube 60 is arranged between the cannula 14 and the push-offtube 36. It will, however, be appreciated that, if the cover tube 60 isappropriately dimensioned, it can, itself, act as the push-off tube, thepush-off tube 36 then being omitted.

A proximal end of the cover tube 60 carries connectors 68. Theseconnectors 68 engage with the tabs 44 of the cannula 14 so that thecover tube 60 engages with and connects to the cannula 14 to enable theremaining tubes of the nested tubes 12 to move towards a distal end ofthe tubes 12 so that the envelope 28 can protrude beyond the end of thecover tube 60 and the distal end of the cannula 14 as shown in FIG. 38of the drawings. The tabs 44, in turn, engage with the manipulating ring56 to retain the cannula 14 in position relative to the prosthesisdelivery apparatus 16.

In the embodiment shown in FIG. 41, the cover tube 60 has a flaredportion 18 to nest with the remaining tubes 12 of the prosthesisdelivery system 10.

In FIG. 42 of the drawings, a set of nested tubes 12 is provided whichdoes not have the flared portion 18 and is mountable to a distal end ofthe static mixer 22.

It is an advantage of these embodiments that the cover tube 60 obviatesthe need for lubricants to enable the envelope 28 to be inserted into alumen of the cannula 14. The cover tube 60 serves to protect theenvelope 28 as the prosthesis delivery apparatus 16 is inserted into thecannula 14.

It will be appreciated that this embodiment, in use, the incision is ofsuch a size that at least part of the static mixer 22 can be insertedthrough the incision. Due to the flared portion 18 of the nested tubes12, the overall length of the prosthesis delivery apparatus 16 and thesystem 10, itself is significantly shorter than would otherwise be thecase. Because of this, the entire system 10 has improved stability andbalance. The stability and balance improves because the lever arm of thesystem (with the pivot point of the system being at the docking point atthe annulus) has now decreased. Since the length of the system hasshortened, the length which the material must travel to the envelopedecreases, therefore the pressure required to deliver the material alsodecreases. Due to the decreased delivery pressure, the surgeon requiresless work (effort) to deliver the material. Less effort means that thesurgeon's movements are more stable and less jerky. This stabilityallows the clinician a higher degree of control in maneuvering thesystem 10 both to the site at which the prosthesis is to be delivered aswell as while forming the prosthesis at the site. This is enhanced dueto the fact that the nesting of the tubes 12 about the static mixer 22also improves the rigidity of the entire system 10 resulting in lessfree movement of a distal end of the prosthesis delivery apparatus 16 ofthe system 10. This further enhances the clinician's control over thesystem 10. Since the working cannula is fixed and docked relative to thepatient, and all the other nested tubes lock to the working cannula, thepositioning and deployment of the envelope within the disc space isconsistent and repeatable. Also, since all the tubes are fixed relativeto each other, during any process of the implant procedure, the risk ofdamage to the envelope is minimised because movement (laterally and oraxially) of the envelope is minimised. Excessive movement of theenvelope during any part of the implant procedure increases its chancesof being damaged by either the surrounding tissue or other tubes (inparticular the working cannula).

In certain embodiments, there is provided an intervertebral disc implantwhich includes an envelope constructed of at least one stretchableand/or elastically deformable elastomeric material, the envelopeincluding an attaching formation for attachment to an introducer toenable the envelope, in a collapsed state, to be introduced into avolume of an intervertebral disc that has undergone a nucleotomy; and afiller material receivable in the envelope via the introducer to causethe envelope to expand elastically to conform substantially to thevolume in which the envelope is received, in use.

In certain embodiments, there is provided an intervertebral disc implantwhich includes a first object constructed of at least one stretchableand/or elastically deformable elastomeric material, the first objectbeing in communication with second object for attachment to a thirdobject to enable the first object, in a first state, to be introducedinto a volume of an intervertebral disc that has undergone a nucleotomy;and a material receivable in the first object via the second objectwhich results in expansion, or partial expansion of the first objectsuch that the first object substantially conforms to the volume in whichthe first object is received, in use.

In certain embodiments, there is provided an intervertebral disc implantwhich includes an envelope constructed of at least one stretchableand/or elastically deformable elastomeric material, the envelopeincluding means for attaching an introducer to enable the envelope, in acollapsed state, to be introduced into a volume of an intervertebraldisc that has undergone a nucleotomy; and means for introducing a fillermaterial into the envelope via the introducer to cause the envelope toexpand elastically to conform substantially to the volume in which theenvelope is received, in use.

In some embodiments, the envelope is of a silicone material. In someaspects, the envelope is constructed with at least one siliconematerial.

In some embodiments, the attaching formation may comprise a filler tubemountable to the introducer, the attaching formation may include aclosure device to inhibit back flow of filler material. In someembodiments, the attaching formation may comprise a filler tube incommunication with the introducer, the attaching formation may include aclosure device to inhibit back flow of filler material. In some aspects,the attaching formation may comprise a filler tube in communication withthe introducer, the attaching formation may comprise a closure means forinhibiting back flow of filler material. Any suitable closure device maybe employed such as, for example, but not limited to, a one-way, ornon-return, valve, a filler tube extending outwardly from the remainderof the envelope to be closed off in a suitable manner or a filler tubeextending into the interior of the envelope and which is crimped closedby the surrounding filler material upon withdrawal of the introducer.

In certain embodiments, the filler material may comprise a plurality ofdiscrete, biocompatible, or substantially biocompatible elements. Theelements may include, singly or in combination, beads, pellets, elongateelements, irregular shaped elements, collapsible elements, expansibleelements, preformed elements, shape memory elements, partially curedelements, uncured elements, cured elements. The elements may bebiocompatible plastics, biocompatible metals, biocompatible ceramics,organic or biological elements, or a combination of the foregoing.Further, the elements may be provided in a mixture of sizes.

The elongate elements may be selected from the group consisting offibres, lengths of filamentary elements such as lengths of string,bristle carrying elements such as bottle brush-like elements, andhelical elements such as lengths of coiled wires, or combinationsthereof.

The discrete elements may be arranged in suspension in a filler withinthe volume. In certain aspects, the filler is an elastomeric, curablefiller.

In certain aspects, each expansible element may be configured to changefrom a first configuration for insertion into the envelope to a secondconfiguration which causes the envelope to conform substantially to thevolume. In certain aspects, the at least one expansible element may beconfigured to change from a first configuration for insertion into theenvelope to a second configuration. In certain aspects, at least oneexpansible element may be configured to change from a firstconfiguration into a second configuration wherein the secondconfiguration causes the envelope to partial conform to the volume.Further, each expansible element may be configured to be received, inits first configuration, in the introducer for introduction into theenvelope.

In certain embodiments, each expansible element may, in its restcondition, adopt its second configuration. Further, each expansibleelement may include a biocompatible, shape memory alloy, such as, butnot limited to nitinol, which causes the element to adopt its secondconfiguration in the envelope after ejection from the introducer.

In certain embodiments, the filler material may be a foamed materialwhich is introduced in a compressed state via the introducer into theinterior of the envelope where it expands to its relaxed state to causethe envelope to conform to the volume. In certain embodiments, thefiller material may be contain at least one foamed material which isintroduced in a first state via the introducer into the interior of theenvelope where it expands to a second state to cause the envelope toconform, or substantially conform, to the volume. The foamed materialmay be a polymeric material such as a polyethylene.

In certain embodiments, the filler material may comprise a plurality ofdiscrete bands of a resiliently flexible material. In certainembodiments, the filler material may comprise at least in part aplurality of discrete bands of a resiliently flexible material. Thebands may be configured to be arranged concentrically within theenvelope. The bands may have a height approximating that of the volume.

In certain embodiments, the envelope may carry at least one layer of atissue ingrowth material. In certain embodiments, the envelope may alsoincluding, tissue ingrowth materials. In some aspects, where a layer isused, the layer may be a polyester material such as Dacron (RegisteredTrade Mark).

In certain embodiments, there is provided an intervertebral disc implantwhich includes an envelope, the envelope including an attachingformation for attachment to an introducer to enable the envelope, in acollapsed state, to be introduced into a volume of an intervertebraldisc that has undergone a nucleotomy; and a filler material receivablein the envelope after placement of the envelope in the volume of thedisc, in use, to cause expansion of the envelope to conform to thevolume, the filler material comprising a plurality of discrete, elongateelements introducible, via the introducer, into an interior of theenvelope.

The envelope may be of an expansible material such as an elastomericmaterial having an elongation of at least 100% and, in some aspects, upto about 1000%, for example, silicone. Elastomeric materials such assilicone can have an elongation up to 250%, 500%, 750%.

In certain embodiments, there is provided an intervertebral disc implantwhich includes an envelope, the envelope including means for attachmentto an introducer to enable the envelope, in a collapsed state, to beintroduced into a volume of an intervertebral disc that has undergone anucleotomy; and a filler material receivable in the envelope and meansfor placement of the envelope in the volume of the disc, in use, tocause expansion of the envelope to conform to the volume, the fillermaterial comprising a plurality of discrete, elongate elementsintroducible, the introducer means, into an interior of the envelope.

The envelope may carry at least one layer of a tissue ingrowth material.Further, the envelope, in certain embodiments, may define a filleropening and may include a closure element for closing the opening afterintroduction of the filler material. In certain aspects the envelope mayhave a filler opening means and may include a closure means for closingthe opening after introduction of the filler material.

In certain embodiments the elongate element may be selected from thegroup consisting of fibres, lengths of filamentary elements, bristlecarrying elements and helical elements, or combinations thereof.

The elongate elements may be arranged in suspension in the filler withinthe volume. In some embodiments, the filler may be an elastomeric,curable filler.

In certain embodiments, the elongate elements may comprise a pluralityof discrete bands of a resiliently flexible material. The bands may beconfigured to be arranged concentrically within the envelope.

In certain embodiments, the elongate elements may be expansibleelements. Each expansible element may be configured to change from afirst configuration for insertion into the envelope to a secondconfiguration which causes the envelope to conform substantially to thevolume. Each expansible element may be configured to be received, in itsfirst configuration, in the introducer for introduction into theenvelope. Further, each expansible element may, in its rest condition,adopt its second configuration.

In certain embodiments, there is provided an intervertebral disc implantwhich includes an envelope of a stretchable and elastically deformableelastomeric material the envelope including an attaching formation forattachment to an introducer to enable the envelope, in a collapsedstate, to be introduced into a volume of an intervertebral disc that hasundergone a nucleotomy; and a filler material receivable in the envelopevia the introducer to cause the envelope to expand elastically toconform substantially to the volume in which the envelope is received,in use, the filler material being a foamed material which is introducedin a compressed state via the introducer into the interior of theenvelope where it expands to its relaxed state to cause the envelope toconform to the volume.

The foamed material may be a polymeric material. The envelope may carryat least one layer of a tissue ingrowth material. The envelope maydefine a filler opening and may include a closure element for closingthe opening after introduction of the packing material.

In certain embodiments, there is provided an intervertebral disc implantwhich includes an envelope, the envelope including an attachingformation for attachment to an introducer to enable the envelope, in acollapsed state, to be introduced, in a minimally invasive manner, intoa volume of an intervertebral disc that has undergone a nucleotomy; anda filler material receivable in the envelope after placement of theenvelope in the volume of the disc, in use, to cause expansion of theenvelope to conform to the volume, the filler material comprising, incombination, a curable filler material and a plurality of discrete,biocompatible elements contained, in use, in the filler material withinthe envelope.

The elements may include, singly or in combination, beads, elongateelements and expansible elements. The elongate elements may be selectedfrom the group consisting of fibres, lengths of filamentary elements,bristle carrying elements and helical elements.

Each expansible element may be configured to change from a firstconfiguration for insertion into the envelope to a second configurationwhich causes the envelope to conform substantially to the volume.Further, each expansible element may be configured to be received, inits first configuration, in the introducer for introduction into theenvelope. Each expansible element may, in its rest condition, adopt itssecond configuration.

The filler may be an elastomeric, curable filler.

In certain embodiments, there is provided an intervertebral disc implantwhich includes an envelope of a stretchable and elastically deformableelastomeric material, the envelope including an attaching formation forattachment to an introducer to enable the envelope, in a collapsedstate, to be introduced into a volume of an intervertebral disc that hasundergone a nucleotomy; and a filler material receivable in the envelopevia the introducer to cause the envelope to expand elastically toconform substantially to the volume in which the envelope is received,in use, the filler material being an elastomeric material having aviscosity of at least 500 cP. In certain aspects, the filler materialmay have a viscosity of at least 1000 cP, of at least 5000 cP, of atleast 10000 cP, of at least 50000 cP, of at least 100000 cP, of at least500000 cP.

In certain embodiments, there is provided an intervertebral disc implantwhich includes an envelope receivable in a volume of an intervertebraldisc that has undergone a nucleotomy, the envelope defining a pluralityof chambers, the chambers being configured so that, when at leastcertain of the chambers contain a filler material, the envelope conformssubstantially to the volume of the disc; a filler material receivable inthe at least certain of the chambers; and at least one of the chambershaving a filler mechanism associated with it.

The chambers may be defined by wall portions of the envelope, wallportions of some of the chambers being of a different wall thicknessthan wall portions of other chambers. In addition, wall portions of someof the chambers may be of a different material than wall portions ofother chambers. Still further, the filler material receivable in atleast one of the chambers may differ from the filler material that isreceivable in at least one other of the chambers.

The envelope may include an attaching formation for attachment to atubular introducer to enable the envelope, in a collapsed state, to beintroduced, in a minimally invasive manner, into the volume of the disc.

Each chamber in which filler material is receivable may have a fillermechanism associated with it. The filler mechanism may be a one-waydevice that, upon closure, inhibits back flow of filler material.Preferably, the filler mechanism of an outer chamber of the envelope maybe implemented as the attaching formation.

In certain embodiments, the system for implanting an intervertebral discimplant, comprises:

an implant as disclosed herein; and an introducer, the introducercomprising a plurality of filler tubes, each tube communicationindependently of any other tube with its associated chamber of theenvelope for charging filler material into the associated chamber.

In certain embodiments, there is provided an intervertebral disc implantwhich includes at least one element which changes from a firstconfiguration for insertion into a volume of an intervertebral disc thathas undergone a micleotomy to a second configuration in which the atleast one element conforms substantially to the volume, the at least oneelement being configured to be received, in its first configuration, inan introducer to be inserted into the volume of the disc.

The at least one element, in its first configuration, may be elongateand, in its second configuration, may adopt a shape conformingsubstantially to the volume. The at least one element may include abiocompatible, shape memory alloy which causes the element to adopt itssecond configuration in the volume after ejection from the introducer.

Further, in certain embodiments, the at least one element, in itsrelaxed state, may be in the first configuration, the at least oneelement including a retention device for retaining the at least oneelement in the second configuration after ejection from the introducer.

In certain embodiments, the implant may include an envelope receivablein a collapsed state in the volume; and a plurality of the elementsreceivable in the envelope, the plurality of elements causing theenvelope to expand substantially to conform to the volume.

In certain embodiments, there is provided a system for implanting anintervertebral disc implant as disclosed herein the systems including anintroducer having a proximal and a distal end, a mount for the envelopeof the implant being arranged at or adjacent the distal end of theintroducer; a source of filler material connectable to the proximal endof the introducer, and a displacement mechanism for displacing thefiller material along the introducer to be ejected from the introducerinto the envelope, in use.

The introducer may comprise at least one tubular member. Instead, theintroducer may comprise at least two tubular members arranged in atelescopic fashion, the tubular members being reciprocally displaceablerelative to one another.

An innermost one of the tubular members may carry the displacementmechanism. The displacement mechanism may comprise a ratchet arrangementfor urging the filler material along the introducer into the envelope.

Further, the envelope may include a flow control device arranged at aninlet opening to the envelope for inhibiting back flow of the fillermaterial from the envelope. The equipment may include a flow controldefining member, the flow control defining member being separate fromthe envelope and being arranged at the inlet opening to the envelope.

A distal end of the filler member may carry an engaging member whichengages the flow control device to at least partially open the flowcontrol device and to allow the interior of the envelope to be evacuatedprior to being charged with the filler material. The envelope may carrya marker arrangement on an exterior surface for enabling the envelope tobe used to assess dimensions and a shape of the cavity and positioningof the envelope in the cavity.

The filler material may be of an elastomeric material capable ofabsorbing shock and withstanding compressive, tensile, bending andtorsional forces. The envelope and the filler material may be of anelastomeric material having a Shore Hardness in the range of about 5 to90 A. The shore hardness may be between 5 and 15 A, 15 and 25 A, 25 and35 A, 35 and 45 A, 45 and 55 A, 55 and 65 A, 65 and 90 A. Preferably,the envelope and the filler material are of a silicone rubber material.

The envelope may be of an elastomeric material capable of expanding toup to 3, 4, 5, 10, 25, 50, 75 or 100 times its relaxed state. Theenvelope is preferably expanded to be stretched and retained undertension after being charged with the filler material.

The envelope may include a neck portion, the neck portion defining azone of weakness for facilitating separation of the envelope from thedelivery device. Further, the envelope may include a flow control devicearranged at an inlet opening to the envelope for inhibiting back flow ofthe filler material from the envelope. The equipment may include a flowcontrol defining member, the flow control defining member being separatefrom the envelope and being arranged at the inlet opening to theenvelope.

The envelope may carry a marker arrangement on an exterior surface forenabling the envelope to be used to assess dimensions and a shape of thecavity and positioning of the envelope in the cavity.

The filler material may be of an elastomeric material capable ofabsorbing shock and withstanding compressive, tensile, bending andtorsional forces. More particularly, the envelope and the fillermaterial may be of an elastomeric material having a Shore Hardness inthe range of about 5 to 90 A. The shore hardness may be between 5 and 15A, 15 and 25 A, 25 and 35 A, 35 and 45 A, 45 and 55 A, 55 and 65 A, 65and 90 A. The envelope and the filler material may be of a siliconerubber material.

In certain embodiments, there is provided a tissue prosthesis whichcomprises an envelope of a biologically inert, elastically deformablematerial capable of being expanded to conform to an interior surface ofa cavity formed at a site in a patient's body; and a filler materialreceived in a fluent state in the envelope, the filler material being ofthe same class of material as the envelope to form, when cured, togetherwith the envelope, a unified structure.

The envelope may be of an elastomeric material capable of expanding toup to 3, 4, 5, 10, 25, 50, 75 or 100 times its relaxed state. Further,the filler material may be of an elastomeric material capable ofabsorbing shock and withstanding compressive, tensile, bending andtorsional forces. The envelope may be expanded to be stretched andretained under tension after being charged with the filler material.

Both the envelope and the filler material may be of an elastomericmaterial having a Shore Hardness in the range of between about 5 to 90A. The shore hardness may be between 5 and 15 A, 15 and 25 A, 25 and 35A, 35 and 45 A, 45 and 55 A, 55 and 65 A, 65 and 90 A The envelope andthe filler material may be of a silicone rubber material. Preferably,the envelope and the filler material are of a silicone rubber material.However, to promote bonding between the envelope and the fillermaterial, the envelope and the filler material may be of differentgrades of silicone rubber material and may be pre-treated in differentways prior to use.

The envelope may include a neck portion, the neck portion defining azone of weakness for facilitating separation of the envelope from adelivery device. Further, the envelope may include a flow control devicearranged at an inlet opening to the envelope for inhibiting back flow ofthe filler material from the envelope. In an embodiment, the prosthesismay include a flow control defining member, the flow control definingmember being separate from the envelope and being arranged at the inletopening to the envelope.

The envelope may carry a marker arrangement on an exterior surface forenabling the envelope to be used to assess dimensions and a shape of thecavity and positioning of the envelope in the cavity.

In certain embodiments, there may be provided a tissue prosthesis whichcomprises an envelope of a foraminous, chemically inert material shapedto conform, or substantially conform, to an interior surface of a cavityformed at a site in a patient's body in which the envelope is to beplaced; and a filler material received in a fluent state in theenvelope, the filler material being of an elastomeric material which,prior to being cured, is urged into foramens of the envelope to form anintegrated structure which inhibits relative movement between theenvelope and the filler material, in use, and once the filler materialhas cured.

The envelope may be of a knitted biological or synthetic polymericmaterial. More particularly, the envelope may be of a knitted polyestermaterial, such as polyethylene terephthalate (PET). Further, theenvelope may be coated with a material of the same class as the fillermaterial.

The filler material 60 (see, e.g., FIG. 7) may also be constructed of asilicone rubber material which is able to absorb shocks and withstandcompressive, tensile, bending and torsional forces imparted to it bymovement of the vertebrae 12 and 14. In addition, due to the fact thatthe filler material 60 is the same class or type as the material of theenvelope 38, once the filler material has cured in the envelope 38, aunified or single, integrated structure is formed which is resistant todelamination and relative movement between the envelope 38 and thefiller material 60.

One component of certain embodiments is the use of at least one envelopeto confine the filler material. Depending on the particular embodiment,the envelope may function to partially contain, substantially contain,or contain the at least one filler material. The function of theenvelope to contain the filler material may vary from fully containingthe filler material to something less than fully containing the fillermaterial. In certain embodiments, the envelope may be a balloon typestructure, mesh-like structure, a band-like structure, may be comprisedof a multi cavity like structure, may be a foldable structure and/or afoldable structure that has a shape memory or combinations thereof. Insome aspects, the envelope may be expandable and/or stretchable up to50%, 100%, 200%, 300%, 400%, 500%, 600%, 700% or up to 1000%, or greaterthan 1000% of its relaxed volume. In other embodiments, the envelope maybe inelastic, or substantially inelastic. In some aspects of thedisclosed embodiments, means for confining the filler material areprovided. For example, but not limited to, the structures disclosed inthis application. In some embodiments, the envelope may be configured tosufficiently contain the filler material at the desired location beforethe implant, during the method of implant and/or after the implant.

In certain embodiments, the biomaterial may be in the form of abiocompatible or substantially biocompatible polymer compositioncomprising a plurality of parts capable of being aseptically processedor sterilized, stably stored, and mixed at the time of use in order toprovide a flowable composition. In some embodiments, the polymercomposition may contain optionally, other ingredients such asantioxidants, and dyes. In some aspects, upon mixing, the composition issufficiently flowable to permit it to be delivered to the desired siteand there fully cured under physiologically conditions. In some aspects,the component parts are themselves flowable, or can be renderedsufficiently flowable, in order to facilitate their mixing and use.

Additionally, the devices disclosed herein are considered novel in theirown right, and can be used with any suitable biomaterial. In certainembodiments, the devices may be used in combination with a curablesilicone based polymer composition comprising a plurality of partscapable of being aseptically processed or sterilized, stably stored, andmixed at the time of use in order to provide a flowable composition andinitiate cure. Those skilled in the art will, in turn, appreciate themanner in which such polymer compositions can be manipulated to producecured and curing polymers with desired combination of properties withinthe scope of certain embodiments. The silicone can be chemicallycrosslinked, e.g., by the addition of multifunctional or branchedOH-terminated crosslinking agents or chain extenders. The optimal levelof chemical cross-linking improves the compression set of the material,reduces the amount of the extractable components, and improves thebiodurability of the silicone polymer. This can be particularly usefulin relatively soft silicone polymers, such as those suitable for therepair of damaged cartilage. Additional fillers may be added to thepolymer composition such as silica, to alter the hardness, compressionset, tensile strength, tear strength, viscosity, other physical orchemical properties, or combinations thereof. In this manner a balancingof the physical and/or chemical properties with respect to the overallcharacteristics of the polymer, can be achieved.

Additionally, certain polymer systems may contain at least one or more,biocompatible or non biocompatible catalysts that can assist incontrolling the curing process, including the following periods: (1) thescorch time (2) the setting period, and finally, (3) the final cure ofthe biomaterial. Together these three periods, including their absoluteand relative lengths, and the rate of acceleration or cure within eachperiod, determines the cure kinetics or profile for the composition.Suitable examples of the catalyst for the formed polymer will dependupon the polymer material selected. In certain aspects where the polymeris a silicone based polymer the catalyst may be selected from, but notlimited to the following: tin, platinum, peroxide.

As applied to intervertebral disc repair, the inclusion of an “additive”in the prepolymer, previously described and presently preferred byapplicants in formulations for joints other than the disc, is notpresently preferred (though remains optional) for use in the disc. Whenpresent, such an additive can provide several desirable features, bothin the formulation and use of the prepolymer itself, as well as in themixed composition. These features include an improved combination ofsuch properties as moisture cure characteristics, cross-linking,viscosity, compression fatigue, and stability.

Certain preferred compositions provide certain desirable properties,including, but not limited to, hardness, strength, cure characteristicsand combinations thereof.

When cured, suitable materials can be homogeneous, providing the samephysico-chemical properties throughout, or they can be heterogeneous andexhibit varying features or properties. An example of a heterogeneouscomposition, e.g., for use as an intervertebral disc replacement, is acomposition that mimics the natural disc by providing a more rigid outerenvelope (akin to the annulus) and a more liquid interior core (akin tothe nucleus). Such heterogeneous compositions can be prepared by the useof a single composition. e.g., by employing varying states of cureand/or by the use of a plurality of compositions, including varyingcompositions and/or ratios of the same ingredients used to form thecomposition.

Suitable compositions for use certain embodiments are those polymericmaterials that provide an optimal combination of properties relating totheir manufacture, application, and in situ use. In the uncured state,such properties include component miscibility or compatibility, processability, and the ability to be adequately sterilized or asepticallyprocessed and stored. In the course of applying such compositions,suitable materials exhibit an optimal combination of such properties asflow ability, mold ability, and in situ curability. In the cured state,suitable compositions exhibit a desired combination of such propertiesas strength (e.g. tensile and compressive), modulus, biocompatibilityand biostability.

When cured, certain of the disclosed compositions demonstrate adesirable combination of properties, in terms of their conformationalstability and retention of physical shape, resilience during load andunload conditions in situ, dissolution stability, biocompatibility, andphysical performance, as well as physical properties such as density andsurface roughness, and mechanical properties such as load-bearingstrength, tensile strength, shear strength, shear fatigue resistance,impact absorption, wear resistance, and surface abrasion resistance.Such performance can be evaluated using procedures commonly accepted forthe evaluation of natural tissue and joints, as well as the evaluationof materials and polymers in general. In particular, a preferredcomposition, in its cured form, exhibits mechanical properties thatapproximate or exceed those of the natural tissue it is intended toprovide or replace. In some aspects, certain compositions may be capableof deforming and recovering resiliently in situ without plasticdeformation, or substantial plastic deformation. In some aspects,certain compositions may be capable of deforming and recoveringresiliently in situ with an acceptable level of plastic deformation. Insome aspects, certain compositions may be capable of deforming andrecovering resiliently in situ without compression set, or substantialcompression set.

It should be appreciated that certain compositions may be produced thathave a desired combination of the physical and chemical propertiesdiscussed in this application.

With respect to those polymer compositions that are uncured, componentsof such compositions, and the compositions themselves, should bemiscible, compatible and stable under conditions used for sterilizationand during storage and in the course of delivery. They are also capableof flowing to an in situ location, and being cured in situ, using asuitable catalyst, thereafter the cured composition is suitably amenableto conforming, shaping and/or contouring, by the use of the deviceembodiments disclosed herein. Over the course of its use in the body thecured, contoured composition exhibits physiological, physical-chemicaland mechanical properties suitable for use in extended in situapplications.

To achieve these desirable uncured and delivery properties, a “polymersystem”, as used herein refers to the component or components used toprepare a polymeric composition. In an embodiment, a polymer systemcomprises the components necessary to form two parts (as discussedelsewhere herein, together with other ingredients (e.g., catalysts,stabilizers, plasticizers, antioxidants, dyes and the like). Suchadjuvants or ingredients can be added to or combined with any othercomponent thereof either prior to or at the time of or after mixing,delivery, and/or curing.

In choosing an optimal volume ratio for a given formulation, thefollowing may be taken into consideration. The viscosity of the reactiveparts in this temperature range of less than about 10° C., less thanabout 20° C., less than about 30° C., less than about 40° C., less thanabout 50° C., less than about 70° C., must be such to provide anacceptable degree of mixing and injection flow rate without mechanicalfailure of any component of the delivery system including cartridge,static mixer, gun and other components. Preferably, the biomaterial issufficiently flowable to permit it to be delivered (e.g., injected) intothe balloon). While such a material can be as thick as the bone cementpaste, the preferred viscosity is less than 1000 Pa·s, 100 Pa·s, 80Pa·s, 60 Pa·s, 40 Pa·s, 20 Pa·s, 15 Pa·s, 10 Pa·s, 8 Pa·s, or 6 Pa·s. Insome aspects, one preferred viscosity is less than 100 Pa·s. Thecomposition of both reactive parts must be such that these parts arehomogeneous and phase stable in the temperature range of theapplication. The max temperature of the reaction exotherm isproportional to the concentration of the reactive groups in the mixedpolymer. A high concentration of the reactive groups might evolve toohigh reaction exothermal energy and therefore may cause thermal damageto the surrounding tissues. The preferable implant-tissue interfacetemperature is below 70° C., 50° C., or more preferable below 40° C. Itis desirable in some embodiments that the reactive parts stay liquid, orsubstantially liquid, during mixing. The complete or partialsolidification of the reactive part when it comes into contact withanother reactive part or any component of the delivery system or duringmixing may be unacceptable. The certain volume ratio of the componentscan be achieved by different ways such as use of the dual-compartmentcartridges with constant volume ratio or by using the injectors withdelivery rates independently variable for each component.

Many mixing devices and methods have been used for multiple partbiomaterials, such as bone cement and tissue sealant, used in operatingrooms. Static mixers and manual dispenser guns are commonly used fortissue sealant and other multi-component biomaterial mixing anddelivery.

It is important that the two parts of polyurethane pre-polymer are mixedquickly and completely in the operating room in a sterile fashion. Thenumber of mixing elements may vary and depends on the composition of theselected polymer. For example, with certain silicone based polymers, itis possible to use between 6 and 20 mixing elements, between 8 and 15mixing elements, or between 10 and 12 mixing elements.

In certain embodiments, in situ curability may be dependent on thereaction rate, which can be measured by induction time and cure time. Ingeneral, fast cure (short induction time) will improve in situcurability and result in less leachable components. However, inductiontime should also be balanced with adequate working time needed forpolymer injection.

A cured biomaterial of that may be used with certain embodimentspreferably exhibits a compression modulus of between about 0.1 MPa andabout 50 MPa, and more preferably between about 1 MPa and about 25 MPa,when measured using ASTM method D575 A at a physiological strain rangebetween 3 and 20%. In certain embodiments, compositions having acompression modulus considerably below these levels will tend to eitherbulge or extrude from annular defects that may exist or appear, whilethose having a modulus considerably above these levels will tend to betoo hard and cause stress shielding and abnormal high contact stress onthe endplate.

In certain embodiments, the envelope 38 is made from a silicone rubbermaterial having the following characteristics:

a Shore hardness (A scale) in the range from about 20-50;

a tensile strength in the range from about 2700 kPa to 11000 kPa;

an elongation of between about 400% and 800%; and

a tear strength of between about 1700 kg/m and 4500 kg/m.

The filler material 60 is also of a silicone rubber material which,prior to use, is stored in two separate parts. The filler material 60,comprising the combined parts, when mixed in a ratio of 1:1 and cured,has the following characteristics:

a Shore hardness (A scale) in the range from about 20 to 40, moreparticularly, about 25 to 30 and, optimally, about 28;

a tensile strength in the range form about 7000 kPa to about 9500 kPa,more particularly, about 8000 kPa to about 9000 kPa and, optimally,about 8500 kPa;

an elongation in the range from about 550% to 700%, more particularly,about 600% to 650% and optimally, about 640%; and

a tear strength in the range from about 1000 to 2000 kg/m, moreparticularly, about 1250 kg/m to 1750 kg/m and, optimally, about 1500kg/m.

One example of a suitable material for the filler material has thefollowing characteristics after mixing the parts in a 1:1 ratio andafter curing:

a Shore hardness (A scale) of 28;

a tensile strength of 8439 kPa;

an elongation of 639%; and

a tear strength of 1500 kg/m.

The filler material 60 may be treated to contain 5%, by volume, bariumsulphate to appear radio-opaque under X-ray, CT, fluoroscopy and MRI. Inaddition, the filler material 60 contains a catalyst and has a scorchtime of between about 1.5 to 2.5 minutes with a curing time of about 5minutes. When the filler material 60 is charged into the envelope 38 itcauses inflation or expansion of the envelope 38 in an elasticallydeformable manner. Expansion of the envelope 38 can occur to such anextent that, where necessary, the expanded envelope 38 distracts thevertebrae 12 and 14 to restore the original spacing between thevertebrae 12 and 14. By using radio-opacity in the filler material 60,distraction of the vertebrae 12 and 14 can be monitored in real timeusing a fluoroscope or the similar equipment.

Further, the envelope 38 conforms to the shape of the cavity 36. Becausethe envelope 38 expands within the cavity 36 and conforms closely to theshape of the cavity 36, the envelope 38 self anchors within the cavity36 and “extrusion” of a unified prosthesis 100, comprising the envelope38 and the filler material 60, formed through the aperture 30 previouslyformed in the annulus 16 of the disc is inhibited.

The material for the envelope may, depending on the grade or class ofmaterial used, be post cured for a period of time. This is affected byplacing the moulded envelope 38 into an oven, for example, for a periodof about 1 to 4 hours at a temperature of about 150° C. to 180° C.

By having the material of the envelope 38 and the filler material 60 ofthe same type, but different grades or classes, chemical bonding betweenthe materials is enhanced which encourages the formation of theprosthesis 100.

An embodiment of the biomaterial was studied to characterize themechanical and wear behavior of the implant.

Fatigue testing was performed to evaluate the mechanical and wearperformance of the implant over its intended life. Fatigue testing incompression, flexion/extension, lateral bending and axial rotation wereconducted to mimic in vivo physiological ranges. Specimens were loadedto 10 million cycles in compression as suggested by ASTM 2346-05 and 5million cycles in flexion/extension, lateral bending and axial rotation.

The test implant was an annulus model (Silicone Shore Hardness 60 A)with a complete implant (filler material—CSM-2186-14 (NusilTechnologies) and jacket material—MED-4830 (Nusil Technologies) and CalfSerum 30 g/L solution (as per ISO/DIS 18192-1)) injected according toexpected surgical procedure. Six implants were created.

The annulus model was placed between two Perspex constraining plateswhich prevent the model from bulging superiorly and inferiorly. Throughthe annulotomy, the implant was delivered using the equipment describedherein until the implant had completely filled the cavity of the annulusmodel. The annulus model and the implant was placed inside a water bathset to 37° C. and let to cure for at least 1 hour.

6 specimens were glued to the test platens and left to dry for 24 hours.The specimens and test platens were then connected to thespinesimulator. The test stain was filled with calf senrum andmaintained at 37±3° C.

The test execution was as follows:—

1) A compression load of 100N and 600N was applied and the heights ofthe specimens at these loads were measured. This height was taken as thereference heights

2) Specimens were cyclically loaded under the following conditions:—

-   -   Compression        -   Load range:            -   600N to 2000N for 10 000 cycles            -   600N to 1500N for 990 000 cycles        -   Load frequency: 2 Hz    -   Flexion/Extension        -   Bending range: +6/−3°        -   Range frequency: 1 Hz    -   Lateral Bending        -   Bending Range: ±2°        -   Range frequency: 1 Hz    -   Axial Rotation        -   Bending Range: ±2°        -   Range frequency: 1 Hz

3) After the completion of the 1 million compression cycles a 100N and600N load was reapplied to measure the height change.

4) This process was repeated another 9 times such that the specimensunderwent 10 million compression cycles.

5) At the completion of the cycling loading the specimens were left torecover for 24 hours a then 100N and 600N load was reapplied to measurethe height change.

After each million compression cycles the calf serum test medium wascollected and analyzed

Since literature publications have suggested the standing load resultsin approximately 0.5 MPa of pressure in the lumbar discs while discpressures whilst lifting is suggested to be between 1.0 to 2.3 MPa, itwas believed that choosing a loading regime between 600N to 1500N and600N to 2000N would represent a worse case scenario. Theflexion/extension, lateral bending and axial rotations ranges arecomparable to human in vivo conditions as suggested ISO/DIS18192-1. Thefrequency of 2 Hz was chosen so as to not overheat the samples.

In the fatigue test, one of the six specimens was destroyed due to itslipping from the stainless steel platen at about the 5.8 million cyclemark. Tears in the annulus were noticed in all test stations at the 3million cycle mark.

Observations of the CDD graded to the scale below.

Grade 1=Jacket peeling observed

Grade 2=Minor cracks observed

Grade 3=Progression of minor cracks observed

Grade 4=Major crack

Wear particles collected in the test medium were subjected to SEM(Scanning Electron Microscope). The results characterized the size withrespect to shape factor, roundness and equivalent circle diameter. Thetest medium was collected every million cycles and wear particlesextracted. The number of particles found per million cycles wascollated. The number of particles found per sample per million cyclesranged from 137 to 797 particles. The average number of particles permillion cycles was approximately 500 particles. Most particles had ashape factor of between 0.9 and 1 indicating that most of the particlescollated were round. The equivalent circle diameter for most particleswas between 0.1 and 0.3 μm.

EDX (Energy dispersive X-ray spectroscopy) analysis of the wearparticles showed no trace of barium, while silicon, gold and palladiumwere detected. The detection of gold and palladium was due tocontamination via the SEM analysis. A sample of an untested nucleusspecimen was also analyzed under EDX to determine the detectability ofbarium. The analysis showed barium was detected but the wear particlescollected from the fatigue testing did not show any signs of barium.According to supplier of the composition, the barium sulfate particlescontained within the filler material is approximately 1 μm. Hence theEDX analysis is sensitive enough to detect the presence of bariumsulfate particles, but the lack of traces detected by the EDX for theimplant indicated that the implant had not worn, or the wear had notbeen significant enough.

All 5 specimens passed the acceptance criteria which required thespecimens to not split up into more than 3 distinct pieces which aresmaller than the size of the annulotomy. This criterion was chosen asthe mechanical function of the CDD will remain even if it has broken upso long as the CDD is adequately constrained within the annulus. So longas the implant is able to maintain its total volume it will stillfunction as required. The 5 specimens all remained intact in one piecewhen the annulus remains essentially intact. In the tests involvingSpecimens 2 and 4, it was noted that the simulated annulus failedleading to a grading of higher than 1 for these tests at some pointbeyond 5 million cycles. It is noted that a protocol involving thereplacement of the annulus after a set number of cycles, e.g., 2million, may more closely represent the natural regeneration of theannulus that occurs in the body and provide a better measure of theperformance of the CDD. In spite of these shortcomings in the simulatedannulus, the structural integrity of the 5 specimens remained intactafter the fatigue testing and hence the acceptance criteria were met.The EDX analysis on the wear particles generated from the testingprocedure showed no signs of barium or platinum and hence not from thenucleus filler material. The acceptance criteria also required no morethan 10% of the volume lost. From visual observation of the 5 specimens,there were no sites where significant parts of the implants were wornaway. Specimens tested where the annulus model did not fail remainedfully intact with no cracks. The remaining two specimens where theannulus failed had cracks present in them but nonetheless remainedintact as one functional body. Accordingly, the implant is capable ofwithstanding in vivo conditions for 10 years equivalent withsupra-physiological loading.

Supra physiological loads in the lumbar spine may be encountered duringaccidents, thus evaluation of the impact performance of the implant isrequired.

The test set up for shock testing was as follows:

1) Specimens were loaded in compression to 100N to measure the referenceheight.

2) A shock load of 3000N at a rate of 200 kN/min was then applied.

3) Specimens were then unloaded to 100N at a rate of 200 kN/min and holdfor 20 seconds to measure the reference height.

This particular test was performed because a shock load rate of 250mm/min or greater has been suggested by ASTM draft standard WK4863.

Specimen Permanent deformation (mm) 2.1 0.5 2.2 0.5 2.3 0.4 2.4 0.3 2.50.3 2.6 0.4 Mean 0.45 Std. dev. 0.09

The mean permanent height loss for the specimens was 0.45 mm or 3.2%.The permanent deformation of the implant constrained within an annulusmodel is less than 4% o.

In vivo, the lumbar discs encounter both static and dynamic loading.Conducting static testing is essential in understanding the creep andrecovery behavior of the implant under a constant load.

1) Specimens were loaded compression to 100N to measure the referenceheight and then unload.

2) Specimens were loaded in compression to 600N and held continuouslyfor 16 hours.

3) A load of 100N was applied to measure the height following staticcreep

4) Specimen was unloaded for 8 hours for recovery.

5) 100N load was reapplied to measure the recovery and permanentdeformation from that measured in step 1.

6) Steps 1 to 5 was repeated.

This test was performed because a 600N load over 16 hours isapproximately equivalent to a person standing continuously for 16 hours.

The loading regime of the specimens aimed to simulate a person standingcontinuously for two 16 hour periods followed by 8 hours of rest over 48hour period. At the first 600N compression load all specimens crept lessthan 0.2 mm over the 16 hour period which is equivalent to less than1.5% height loss. At the second 600N load all test specimens crept lessthat 0.2 mm, again equivalent to less than 1.5% height loss.

The specimens were also subjected to a 100N reference height before thecommencement of testing. The 100N load was also applied before and afterthe 8 hour no load (rest periods). In average height loss at 100N loadat the end of testing was 0.2 mm when compared to the reference height.The maximum height loss at 100N load occurred after the second 600Nloading period and it showed the height loss at this load wasapproximately 0.3 mm when comparing to the reference height.

This indicates the implant looses minimal height after constant staticloading. The static creep of the implant constrained within anartificial annulus model creeps less than 2% over a 16 hour period.

Other nucleus replacement prostheses, mainly hydrogels require fluidabsorption to form the required dimensional characteristics and thusswelling tests are essential in the mechanical characterization process.The implant is not made from a hydro-expanding material. It allows watermolecules to pass through, therefore this test was not considerednecessary. It was included in this protocol for completeness and toverify the above claim.

Specimens were dried in an oven at temperatures above 100 degrees for aminimum of 4 hours.

1) Specimens were placed within a swell test jig with a plastic plateplaced on top.

2) The jig was then filled with Ringer's solution.

3) A LVDT transducer was used to measure the height change over a 48hour period.

Max. sensor Min. sensor Height Change deflection deflection Fluctuationafter 48 hours Specimen (mm) (mm) Range (mm) (mm) 1 0.02 −0.02 0.04−0.01 2 0.01 −0.01 0.02 0.01 3 0.01 0.00 0.01 0.01 4 0.00 −0.02 0.02−0.01 5 0.00 −0.03 0.03 −0.02 6 0.00 −0.02 0.02 −0.01 Mean 0.01 −0.020.02 −0.01 Std. dev. 0.01 0.01 0.01 0.01

The results the mean height change after 48 hours soaking in Ringer'sSolution was 0 mm. The maximum change in height occurred on specimen 5with a 0.03 mm. The results indicate that the CDD is not affected byswelling through fluid absorption as opposed to hydrogels.

Previous clinical studies of other prostheses have raised concern withextrusion of the device. Therefore, it is important to evaluate the riskof extrusion with the CDD. The proposed surgical procedure used toimplant the CDD is through the creation of an annulotomy. Therefore thisextrusion test will be done on a similar sized annulotomy in anartificial annulus model (this being the worst case opening in theannulus). Because of the characteristics of the implant, it is doesn'treally lend itself to extrusion. This test was performed forcompleteness and no extrusion of any kind or severity was expected.

The implant was partially filled to a volume between 1.5 to 2 ml insidethe annulus cavity to represent a worse case scenario since it wasbelieved that partially filled CDD specimens have a greater chance ofextrusion due to their relative size to the annulotomy opening.

1) Specimens were fatigue loaded for 200,000 compression cycles underthe following conditions:

Compression

-   -   Load range: 600N to 2000N    -   Frequency: 2 Hz

Flexion/Extension

-   -   +6/−3° Frequency: 1 Hz    -   Frequency: 1 Hz

Partially filled implants (30 to 50% fill) were subjected to fatiguetesting in compression and flexion/extension. The position of theannulotomy was positioned such that the annulotomy underwent tensionduring the flexion cycle. During this cycle the implant and theencompassing annulus model are flexed to 6 degrees. This accompaniedwith the compression cycles subjected the implant to conditions thatwould induce expulsion. After 200,000 cycles no expulsions orprotrusions were observed in any of the test specimens. Detachmentbetween the superior section of the annulus and the stainless steel testplaten occurred in specimens 3 and 4 after the 200,000 cycles.

A partially filled implant (30 to 50% fill) was chosen as a smallersample would more likely extrude than a fully filled CDD as the size ofthe annulotomy remained the same. Also the implant was inflated throughthe annulotomy and hence the proximal end of the implant sits at theinner edge of the annulotomy. In addition to this test, no expulsionswere observed during the fatigue test in which the implant was subjectedto multi directional testing to 10 years equivalent with an annulotomypresent. From the literature expulsion studies have been conducted usingcadaveric models. This test was performed in an artificial annulus modelas it would allow testing to be conducted to 200,000 cycles which wouldotherwise not be possible in a cadaveric test model due to tissuedegeneration.

No expulsions or protrusions were observed for all 6 test articles after200,000 cycles hence the acceptance criteria were met. In addition noexpulsions were observed during any point of the fatigue test.

Due to the viscoelastic nature of the implant, it is expected to creepunder an applied load. This test aims to evaluate this. An implantspecimen was filled into a 25.4 mm diameter cylindrical mould toapproximately 10.5 mm in height.

1) The specimen was placed between delrin platens

2) The specimen was then subjected to a 253N (0.5 MPa) compression loadfor 16 hours.

3) Specimen was then unloaded (no load applied) for 8 hours to recovery.

4) Steps 2 and 3 were repeated a further three times such that thespecimen was subjected to four 16 hour loading regimes over a four dayper period.

Time Point Height Loss (%) End of first session −3.47 Start of 2^(nd)session −0.71 End of 2^(nd) session −4.18 Start of 3^(rd) session −1.10End of 3^(rd) session −4.44 Start of 4^(th) session −1.69 End of 4^(th)session −4.53

The results show a gradual decrease in height during the loading periods(approximately 3.5% per 16 hour period). During the 8 hour rest periodsthe specimen recovered approximately 80% of the height loss. Duringloading on the fourth day aspects of recovery was observed. The implantshowed signs of permanent deformation and recovery after loading due toits viscoelastic properties.

Conducting mechanical tests on aged samples is critical in ensuring themechanical performance of the implant is not compromised over time.Samples were aged using heat as proposed by the literature. The implantswere aged using a 10 degree temperature acceleration method suggested bythe literature. All specimens were subjected to 11 hours in a dry ovenat 177° C. and then placed in a saline water bath for 46 days at 87° C.This subjected the specimens to 24 years equivalent worth of aging. Ithas been suggested that an increase of 10 degrees C. doubles the agingprocess. Therefore placing the samples to the above heating conditionswill be equivalent to at least 24 years worth of aging.

Specimens were glued to the test platens and left to dry for 24 hours.The specimens and test platens were then connected to thespinesimulator. The test stain was filled with calf serum and maintainedat 37±3° C.

The test execution was as follows: —

1) A compression load of 100N and 600N was applied and the heights ofthe specimens at these loads were measured. This height was taken as thereference heights

2) Specimens were cyclically loaded under the following conditions:—

-   -   Compression        -   Load range:            -   600N to 2000N for 10 000 cycles            -   600N to 1500N for 990 000 cycles        -   Load frequency: 2 Hz    -   Flexion/Extension        -   Bending range: +6/−3°        -   Range frequency: 1 Hz    -   Lateral Bending        -   Bending Range: ±2°        -   Range frequency: 1 Hz    -   Axial Rotation        -   Bending Range: ±2°        -   Range frequency: 1 Hz

3) After the completion of the 1 million compression cycles a 100N and600N load was reapplied to measure the height change.

All specimens were loaded to 100N and 600N and the heights measured atthis load. After the specimens were subjected to cyclic load the 100Nand 600N load was reapplied to measure the heights. These values werecompared to the reference heights.

Height loss at 100N Height loss at 600N Specimen reference loadreference load 3.1 0.53 1.4 3.2 0.49 1.3 3.3 0.44 1.3 3.4 0.45 1.1 3.50.55 1.3 3.6 0.46 1.2 Mean 0.49 1.3 Std. dev. 0.1 0.1

The average height loss at the 100N and 600N reference loads was 0.49 mmand 1.3 mm, respectively. The height measurements after 1 million cyclesshowed the aged specimens performed better than the fatigue specimens interms of height loss.

No cracks were observed on any of the specimens and aging does not haveany serious adverse mechanical effects on the CDD.

Height maintenance is an important mechanical function in a nucleusreplacement device. This test aims to evaluate the dynamic fatigueproperties of the CDD constrained within an artificial annulus model.

The filler material (CSM-2186-14) was injected into the annulus cavityvia a 4 mm annulotomy and left to cure for 24 hours.

1) Specimen was placed between the two delrin platens (see FIG. 10.1)

2) Specimens were subjected to a 509N compressive load to reduce thecreep affects.

3) The specimen was then subjected to a cyclic compression loadingbetween 509N and 1730N at 2 Hz for 100,000 cycles.

The change in peak height during the cyclic loading and the change inheight during the cyclic loading was measured.

The maximum and minimum height (at 509N and 1730N load respectively) ofthe samples was recorded for the predetermined cycles. A reduction inheight during the 1 million cycles (dynamic creep) was evident in bothsamples where the greatest observable difference was recorded betweencycles 1 and 5,000. The rate of height loss (dynamic creep) plateaus outbetween cycles 5,000 to 100,000.

Cycling the specimens between 509N (0.5 MPa) and 1730N (1.7 MPa) isapproximately equivalent to a person standing in a relaxed position toand lifting a 20 kg. Cycling the implant in this fashion is thus a grossover-exaggeration of what a person would encounter in everyday lifehowever the aim was to test the lifecycle of the device in a worst casescenario at accelerated loading conditions and thus justified.

The dynamic creep of the CDD constrained within an annulus model over100,000 cycles was less than 5%.

A finite element analysis of the implant was also performed, and thefollowing items were observed from the model.

The implant is believed to restore the nucleotomy model tonear-physiological axial displacement when the implant completely fillsthe nucleotomy volume. Data indicates that the implant axialdisplacement approaches the result provided by the intact model. Incontrast to this, the untreated nucleotomy results in an abnormally lowaxial stiffness.

The extent of the nucleotomy relative to the nucleus volume does nothave as pronounced effect on the axial stiffness when compared to theextent the implant fills the nucleotomy. This is apparent when theimplant model (based on a finite element analysis) (100% filling ofnucleotomy) is compared with the partial implant (see, FIG. 86). Thepartial implants and new inflation models (30%, 70%) do not showsignificant difference between each other. This phenomenon relies on theassumption that a void remains between the implant and the nucleotomy inthe partial-fill implant.

In reference to FIGS. 3-7, when the nucleus pulposus 18 has beenremoved, a residue 64 remains about the inner surface of the annulusfibrosis and on the end plates 20 of the vertebrae 12 and 14. Thisresidue 64 is of an irregular shape. Therefore, in charging the envelope38 with the filler material 60, it is necessary to monitor the chargingof the filler material 60 into the envelope 38. This is done by asensing arrangement. In one embodiment, the sensing arrangementcomprises a pressure sensor 66 at an inlet to the envelope 38. Inanother embodiment, the sensing arrangement comprises a volume sensor 68arranged at an outlet of the dispenser 62 for monitoring the volume offiller material 60 dispensed. The sensing arrangement could, in additionor instead, be a flow rate sensor which monitors the rate of flow of thefiller material 60.

Yet a further method of monitoring filling of the envelope 38 ismonitoring back flow of filler material 60 from between the envelope 38and the distal end of the delivery device 40. As the filler material 60oozes out it may loosen the envelope 38 allowing the delivery device 40to be removed.

In FIGS. 43-76, reference numeral 10 generally designates anintervertebral disc implant in accordance with various embodiments. Theimplant 10 comprises an envelope 12 in which a filler material 14 isreceived. The implant 10 is intended for use in replacing a nucleuspulposus of an intervertebral disc 16 arranged between adjacentvertebrae 18, 20. Generally, the procedure is formed in a minimallyinvasive manner as will be described in greater detail below. It willalso be appreciated that the procedure may be conducted in apercutaneous manner as described herein and in greater detail below.

It will be appreciated that the disc 16 comprises an annulus 22circumscribing a nucleus pulposus. The intervertebral disc implant 10 isintended to replace a degenerate nucleus pulposus of the disc 16. Thus,the implant 10 is implanted after the disc 16 has undergone a nucleotomyto remove the nucleus pulposus.

In the embodiments illustrated in FIGS. 43 to 53, the envelope 12 of theimplant 10 is of a stretchable and elastically deformable elastomericmaterial such as a silicone material. Various filler materials 16 can beused with the envelope 12 in order to mimic as closely as possible thebiomechanical actions of a natural, healthy nucleus pulposus.

In the embodiment shown in FIGS. 43 a, 43 b and 43 c, the fillermaterial 14 comprises beads 24 held in suspension in a curableelastomeric material 26. The elastomeric material 26 is, once again,preferably a silicone material.

The beads 24 are of a biocompatible material. Thus, for example, thebeads 24 could be of a suitable biocompatible plastics material, abiocompatible metal material, a biocompatible ceramic material orsuitable biological material such as proteoglycans. The beads 24 may behomogenous in the sense that all the beads are of the same size and samematerial. Instead, the beads 24 may be of different sizes and differentmaterials in order to obtain particular biomechanical characteristicsfor the implant 10.

In certain embodiments, the beads need not be spherical in shape. Theycould, instead, be any one of bullet shaped, polygonal, triangular,heart shaped, kidney shaped, ovoid, oblong, crescent shaped, cubic,elongated, conical, trapezoidal, prismatic irregular, or combinationsthereof. In some aspects, a preferred shape is one which allows forconvenient and unobstructed insertion. Thus, preferably, the beads 24have radiussed corners and/or edges to minimise the risk of damaging theenvelope 12.

The beads may range in size from 0.01 mm to 5 mm and, optimally, anysize in order that the beads 24 can be introduced into the interior ofthe envelope 12 by an introducer.

In the embodiment shown in FIGS. 44 a, 44 b and 44 c, the fillermaterial 14 comprises elongate, filamentary elements carried insuspension in the silicone 26. The filamentary elements are“string-like” elements which are, once again, of suitable biocompatiblematerials. The elements typically have lengths not exceeding 1 cm. Onceagain, the lengths of the filamentary elements 26 may all be the same orthey may differ to obtain the desired biomechanical characteristics forthe implant 10.

In FIGS. 45 a, 45 b and 45 c, the filler material 14 comprises fibres 30in suspension in the silicone 26. The fibres 30 are, typically, oflengths less than 3 mm. As in the case of other disclosed embodiments,the fibres are made up of suitable biocompatible materials. The fibres30 are selected either to all be of substantially the same material andlengths or they may be of different materials and of different lengthsto obtain the desired biomechanical characteristics for the implant 10.

FIGS. 46 a, 46 b and 46 c illustrate certain embodiments in which thefiller material 16 comprises spherical elements contained in theenvelope 12. The spherical elements 32 are of suitable biocompatiblematerials such as biocompatible plastics, biocompatible metals,biocompatible ceramics or biological material. The spherical objects maybe in a range of sizes not exceeding 3 mm to 4.5 mm (e.g., not exceeding3, 3.25, 3.5, 3.75, 4, 4.25.4.5, etc.) in order to be able to beintroduced into the interior of the envelope 12 via an introducer aswill be described in greater detail below.

The spherical elements 32 are typically provided in a range of sizes toprovide compacted packing of the filler material 14 within the interiorof the envelope 12 but still allowing compressive stresses on the disc16 to be transmitted to the annulus 22 of the disc.

In FIGS. 47 a, 47 b and 47 c, the filler material 14 comprises one ormore lengths of string-like elements 34. Each element 34 may typicallyhave a length less than 10 cm and a diameter less than 3.5 mm to 4 mm.Sufficient lengths of elements 34 are provided to pack the interior ofthe envelope 12 to provide the necessary weight bearing functions of theimplant 10. These elements 34 are, once again, of biocompatiblematerial.

Referring now to FIGS. 48 a, 48 b and 48 c, the filler material 14comprises a plurality of short lengths of fibre 36. The fibres 36 are,typically, about 2 to 3 mm long and are of biocompatible materials. Thefibres 36 are packed into the interior of the envelope in a compactedstate in order to impart the required biomechanical characteristics tothe implant 10. Once again, the fibres 36 may be of different materialsand different lengths.

In FIGS. 49 a, 49 b and 49 c, the filler material 14 comprises aplurality of bottlebrush-like elements 38. The bottlebrush elements 38are of the form having a central spine with bristles projecting radiallyoutwardly from the spine. The bristles are folded on to the spine forintroduction into the envelope 12 via an introducer.

Once again, the bottlebrush elements 38 are packed, in a compactedstate, within an interior of the envelope 12 to impart the necessarybiomechanical characteristics to the implant 10. The bottlebrushelements 38 may be of biocompatible plastics materials. In addition, thebottlebrush elements may be in the form of biocompatiblemetals/biocompatible plastics combinations. An example of this would bea bottlebrush element 38 having a metal spine with plastics bristles.Still further, the bottlebrush elements 38 could be of all metalconstruction. The elements 38 typically have a length of less than about1 cm, preferably about 5 mm. When the bristles are folded on to thespine for insertion into the introducer, the element 38 may have adiameter not greater than about 3.5 mm to 4 mm.

Once again, if desired, bottlebrush elements of mixed sizes andmaterials may be used together to impart the desired biomechanicalcharacteristics to the implant 10.

Referring now to FIGS. 50 a, 50 b and 50 c, the filler material 14comprises lengths of helical or coiled wires 40. The coiled wires 40 arepacked, to be in a compacted state, in the interior of the envelope 12in order to provide the necessary biomechanical characteristics. Thecoiled wires, in their relaxed state, may typically be less than about 1cm in length, preferably, about 5 mm in length. The wires 40 may be ofbiocompatible plastics or biocompatible metals. As in the previousembodiments, wires 40 of different lengths and different materials maybe used together, if desired, in the implant 10.

In the embodiment shown in FIGS. 51 a, 51 b and 51 c, the fillermaterial 14 comprises a plurality of discrete bands 42 of a resilientlyflexible, biocompatible material arranged concentrically within theenvelope 12 to form the implant 10. The bands 42 have a thickness notexceeding about 1 mm and a height not exceeding of about 9 mm.

The filler material 14 in the embodiments illustrated in FIGS. 52 a, 52b and 52 c are made from a foamed material 44. The foamed material 44 isintroduced, in a compressed state, via the introducer into the interiorof the envelope 12. Once the introducer is withdrawn, the foamedmaterial 44 expands to a relaxed state to cause the envelope 12 toconform to the volume in which it is placed. Typically, the foamedmaterial 44 is a polymeric material such as a polyethylene.

In FIGS. 53 a, 53 b and 53 c, the filler material 14 is silicone oilhaving a viscosity of at least 500 cPs. This material exhibitssurprisingly good biomechanical characteristics and mimics closely anatural, healthy nucleus pulposus of an intervertebral disc.

In the embodiments described above, as previously described, theenvelope 12 is generally of a silicone material which has an elongationof up to 1000%, where it can expand elastically without plasticallydeforming. In certain circumstances, it may not be necessary to have theenvelope have such extensive elongation and, if desired, the envelopecould be made of other materials in appropriate circumstances, such as,for example, woven metal fibres such as stainless steel, nitinol, chromecobalt, titanium, or the like, or combinations thereof. Instead, theenvelope may be of a plastics material such as a polymeric material likepolytetrafluoroethylene.

Further, in the embodiments described above, the implant 10 makes use ofan envelope. In certain circumstances, the implant 10 may not require anenvelope 12. In the embodiments illustrated in FIGS. 54 and 55, theinsert 10 comprises an elongate element 48 of a suitable resilientlyflexible material, such as a silicone material. In this embodiment, theelement 48 is inserted into the volume resulting after the nucleotomyhas been performed on the disc 16 in an elongated state as shown in FIG.54 of the drawings. Use of a stylet 50 maintains the elongate element inits extended state. When the elongate element 48 is inserted into thevolume, the stylet 50 is withdrawn causing the elongate element 48 toadopt the configuration shown in FIG. 55 in which the element 48substantially fills the volume. In a similar embodiment to this, aplurality of such elements 48 are used, either side by side or one ontop of the other in layers, to conform to the volume. In the lattercase, the elements 48 may, if desired, be inserted into an envelope (notshown).

FIGS. 56 and 57 show a similar embodiment of implant 10 in which theimplant 10 comprises a plurality of doughnut-like members 52interconnected serially to form an implantable element 54. Once again,the implantable element 54 has a stylet 56 associated with it to aidimplantation.

In a relaxed state, the implantable element 54 adopts the configurationshown in FIG. 57. The implantable element 54 is implanted, in its firstconfiguration, as shown in FIG. 56, into the volume of the disc 16.Withdrawal of the stylet 56 causes the implantable element 54 to becompressed, as shown in FIG. 57, into a second configuration in which itconforms substantially to the volume of the disc 16.

Once again, in a similar manner to the embodiment described above withreference to FIGS. 54 and 55, a plurality of the implantable elements 54may be used, either side by side or in layers to conform to the volumeof the disc 16. In this case, the implantable elements 54 may bereceived in an envelope (not shown).

Referring now to FIGS. 58 and 59, yet a further embodiment of an implant10 is illustrated.

In this embodiment, the implant 10 comprises an elongate implantableelement 58 which, optionally, has a stiffening spine 60. The implantableelement 58 is, typically, an elastomeric material such as, for example,silicone. The spine 60 is of a shape forming material or shape memoryalloy such as nitinol.

The implantable element 58 is inserted via an introducer into the volumeof the disc 16. One or more lengths of the implantable elements 58 maybe used to cause the implantable elements 58 to conform to the shape ofthe volume in order to function as a replacement nucleus pulposus of thedisc 16.

In FIG. 60, an embodiment similar to that described above with referenceto FIGS. 58 and 59 is illustrated. In this embodiment, the implant 10comprises two, coiled implantable elements. Each implantable element 62has a coiled shaped in its relaxed state. This coiled shape may beimparted by a stiffening spine of shape forming alloy such as nitinol(not shown). Instead, the implantable elements 62 may be formed in sucha manner that, in their relaxed state, they adopt a coiledconfiguration.

In this embodiment, the implantable elements 62 are straightened forintroduction into the volume of the disc 16. Once in the volume, theimplantable elements 62 coil in oppositely directed orientationssubstantially to fill the volume resulting from removal of the originalnucleus pulposus of the disc 16.

In FIGS. 61 and 62, the implant 10 comprises a single, implantableelement 64. The implantable element 64 is of an elastomeric material,such as silicone, and, in its relaxed states, is in a shape which willsubstantially conform to the volume of the disc into which the element64 is to be imparted.

To aid in implantation of the element 64, a plurality of cuts 66 aremade in the element. These cuts 66 cause “hinges” 68 to be formed aboutwhich the parts of the element on either side of the cut 66 can hinge tostraighten the element 64 to be implanted via an introducer into thevacated volume of the disc 16.

The embodiments of the implants shown in FIGS. 63 and 64 are similar tothose shown in FIGS. 61 and 62. In the embodiment shown in FIG. 63 ofthe drawings, the implant 10 comprises a single implantable element 70formed into a snake-like configuration, in its relaxed state. Theimplantable element 70 has a convex profile. The embodiment shown inFIG. 64 of the drawings is of a similar form with the distinction thatan implantable element 72 of the implant 10 of the embodiment shown inFIG. 64 has a concave profile. Once again, in both embodiments, theimplantable element 70, 72 is extended into a straight configuration forimplantation via an introducer. Once in the volume of the disc 16, theimplantable element 70, 72 adopts its relaxed, illustrated configurationsubstantially to conform to the volume of the disc 16.

Yet a further embodiment of an implant 10 is shown in FIGS. 65-67. Onceagain, with reference to the previous embodiments, like referencenumerals refer to like parts, unless otherwise specified.

In this embodiment, an attaching formation 74 of the envelope 12 isshown. It is to be understood that the envelope 12 of each of theembodiments described above also includes such an attaching formation.The attaching formation 74 is used for attaching the envelope to anintroducer 76 (FIG. 74). The attaching formation 74 is in the form of afiller tube. The filler tube 74, in this embodiment, extends radiallyoutwardly from the body of the envelope 12. A closure device in the formof a duck-billed valve 78 is arranged at a distal end of the filler tube74. When the introducer 76 is inserted into the filler tube 74, itcauses the valve 78 to open. Withdrawal of the introducer 76 from thefiller tube 74 causes the valve 78 to close.

In this embodiment, the envelope 12 has an annular region 80 of areasonably rigid material. The material of the annular region 80 is morerigid than material forming upper and lower members 82 of a central partof the envelope 12. The annular region 80 of the envelope 12 bearsagainst the annulus 22 of the disc 16, in use. When the filler material14 is charged into the interior of the envelope 12, the members 82expand outwardly as shown by the upper member 82 in FIG. 66 of thedrawings to bear against the vertebrae 18, and so cause the envelope 12to conform substantially to the volume of the disc 16.

It is to be noted that both members 82 carry, on their outer surfaces, alayer of tissue ingrowth material 84. The material 84 is, typically, apolyester material such as that sold under the registered trade markDacron.

The annular region 80 is of a substantially non-stretchable materialwhile the members 82 are made to stretch and expand in volume. Thematerial of the annular region 80 is still sufficiently flexible toenable the envelope 12 to be collapsed to be inserted via an introducerinto the vacated volume of the disc 16.

FIGS. 68-73 show various embodiments of a multi-chambered envelope 12.As shown in FIG. 69, the envelope 12 has a plurality of chambers 86,each of which is fed by a collapsible delivery tube 88. Each deliverytube 88 has a valve (not shown) at its distal end. Filler material isintroduced into each of the chambers 86 of the envelope 12 via theassociated delivery tube 88. Thus, filling of each of the chambers 86can occur independently. In addition, the filler material received ineach chamber 86 may differ from the filler material received in anyother chamber 86. Still further, certain of the chambers 86 may, incertain circumstances, not have any filler material at all.

A sample of the construction of the envelope 12 is shown in FIGS. 71-73.The envelope 12 has an upper member 90 and a lower member 92interconnected by a sidewall 94. A plurality of partitions 96 extend inthe interior of the envelope 12 between the upper member 90 and thelower member 92. The partitions 96 are configured to have strongcompressive load bearing capabilities but to collapse in shear as shownin FIG. 73 of the drawings. Thus, for introduction of the envelope intothe vacated volume of the disc 16, the partitions 96 are collapsed, asshown in FIG. 73 by moving the members 90 and 92 laterally relative toeach other.

It will be appreciated that various other configurations ofmulti-chambered envelopes 12 can be formed by using different materialsfor different chambers of the envelope and/or filling the variouschambers with different filler materials 14, as described above.

In FIGS. 74 and 75, a system, in accordance with another embodiment, forimplanting an intervertebral disc implant is shown and is illustratedgenerally by the reference numeral 100. The system 10 comprises theimplant 10 and an introducer 76. The introducer 76 has an elongatetubular element 102 on a distal end of which is received the attachingformation 74 of the envelope 12. A non-return valve 78 is arranged at adistal end of the attaching formation 74. In the embodiment illustratedin FIGS. 74 and 75, the filler material comprises the balls 32 of theembodiment described above with reference to FIGS. 46 a, 46 b and 46 c.

The annulus 22 of the disc 16 is accessed percutaneously in a patientand an opening is made through the annulus 22. The degenerate nucleuspulposus is removed using ablation, lasers or mechanical means to createa vacated volume. The introducer 76 with the envelope 12 in a collapsedconfiguration on the distal end of the tubular member 102 is insertedthrough the incision so that the envelope 12 is within the volume of thedisc 16.

Filler material 14 is fed through the tubular member 102 of theintroducer 76 into the interior of the envelope 12 to cause the envelope12 to expand to conform to the volume of the disc 16. In the embodimentshown in FIGS. 74 and 75, the filler material is fed through theintroducer via an appropriate displacement mechanism, such as a pump(not shown). Once the envelope 12 has expanded to conform to the volume,charging of filler material 14 into the interior of the envelope 12ceases. The tubular member 102 of the introducer 76 is withdrawn fromthe attaching formation 74 of the envelope 12. Withdrawal of the tubularmember 102 causes the value 78 to close inhibiting leakage of the fillermaterial 14 from within the envelope 12.

It will be appreciated that the balls 32 have been shown merely as oneexample of the type of filler material 14 used with the introducer 76.Other filler materials 14 having discrete elements are also able to beinjected into the envelope 12 of the implant 10 using the introducer 76.

In FIG. 76, part of another embodiment of an introducer is illustrated.In this embodiment, the displacement mechanism for charging fillermaterial 14 into the interior of the envelope 12 comprises adisplaceable element 104. The displaceable element 104 is a sleevereceived within the tubular member 102 of the introducer 76 and which isable to reciprocate relative to the tubular member 102. An inner surfaceof the sleeve 104 carries a ratchet arrangement 106. By reciprocatingthe sleeve 104 relative to the tubular member 102 filler material 14 canbe fed along the introducer 76 into the interior of the envelope 12 bymeans of the ratchet arrangement. The introducer 76 of the embodimentshown in FIG. 76 of the drawings is useful for introducing elongateelements into the interior of the envelope or, in certain circumstances,such as the embodiments shown in FIGS. 54-64 directly into the volumewhere no envelope is used. An example of an implant 10 which would usethe introducer 76 of the embodiment of FIG. 76 is that shown in FIGS. 47a, 47 b and 47 c as well as the embodiment shown in FIGS. 51 a, 51 b and51 c.

It is to be noted that the implant 10 may be used to deliver bioactivesubstances to the annulus 22 of the intervertebral disc 16. Thebioactive substances may be substances which induce cell growth and/orcell reproduction. Further, the implant 10 may be used as a drugdelivery means for active and/or prophylactic treatment at the site ofimplantation. Substances to be delivered may include may include genetelomerase, proteins, cells, autologous chondrocytes and autologous bonemarrow derived mesenchymal stem cells.

Hence, it is an advantage of certain embodiments, that an intervertebraldisc implant is provided which can mimic the biomechanicalcharacteristics of a natural, healthy nucleus fibrosis of anintervertebral disc. It is a particular advantage of certain embodimentsthat an implant and system are provided which enables the implant to beinserted in a minimally invasive manner thereby obviating the need fordrastic surgery. By use of discrete elements for the filler material 14,the biomechanical properties of the implant 10 can be tailored toparticular requirements as desired by a clinician.

The disc is a highly viscoelastic structure and this makes it a veryefficient and effective shock absorbing unit. In a healthy disc, the NPis well hydrated with a very gel like consistency and under the variousmodes of loading, the NP is pressurised and deformed, directing theincident load radially onto the AF and end plates. This creates anintradiscal pressure and load transfer between adjacent vertebrae isfacilitated as the AF fibers are maintained in tension from the hoopstresses which result from the intradiscal pressure. This cooperativemechanism between the NP and AF provides the disc with the ability tosustain compressive loads retain the separation required between theadjacent vertebrae and provides controlled movement. With the onset ofdisc degeneration, brought upon by age or injury, there is a disruptionin the balance between the NP and AF resulting in a destabilization ofthe motion segment. Common parameters which are used to evaluate themobility and stability of the motion segment are neutral zone (NZ) andrange of motion (ROM). In disc degeneration, the NZ (or joint laxity)increases along with its ROM. As the disc degenerates and becomesdehydrated, the NP shrinks and the ability to act as a shock absorbing,energy dissipating mechanism is compromised. A shrinkage in the NPresults in a loss in the intradiscal pressure which then alters thestress distribution through the disc and since the intradiscal pressureis lost, the hoop stresses are lost also. Without the hoop stresses, theannulus is not able to be maintained in a taught orientation, eventuallyleading to delamination and shearing of the annular layers. The loss inintradiscal pressure also creates an increased laxity in the joint andan increase in the joint laxity means that there is a greater range ofmotion from the neutral position that is unsupported and unresisted,indicating an increased level of instability in the segment, adding morestress on the posterior articulating elements and adjacent segments tosustain the loads.

As it can be shown in the kangaroo motion segment study, by implanting anucleus prosthesis, more specifically, one of the prostheses disclosedherein into a degenerate disc or at least a nucleotomised disc, the NZand ROM of the motion segment is capable of being restored to that of anintact disc.

Specifically, the objectives of this study were to evaluate thebiomechanical properties of the device using a cadaveric kangaroo lumbarspine model. The specific research question was whether kinematicvariables differ when treating a motion segment with nucleotomy ornucleotomy then implantation with the exemplary device?

Ten kangaroo spine lumbar motion segments (L3/L4 and L5/L6) with allmusculature, ligamentous tissue and posterior elements removed wereseparated into two equal groups. All specimens were tested in an intactstate (pretreatment) prior to undergoing either a nucleotomy(nucleotomy) or undergoing a nucleotomy with implantation of aconformable elastomeric NR device (such as the devices disclosed herein)and then retested. All samples where tested in lateral bending andflexion-extension on a custom built jig attached and tested at 3.4deg/sec with loads of −1.4 Nm to 1.4 Nm. Kinematic data were collatedfrom the load displacement curve included; Neutral Zone (NZ), Range ofmotion (ROM), and Hysteresis. NZ is defined as the range which thespecimen displaces with zero loads: ROM is defined as range from thestart position to the point of maximal displacement in a givendirection; and Hysteresis is defined as the energy difference betweenloading and unloading cycles on a stress-strain curve.

Before and after treatment analysis was performed using the StudentPaired t-test with alpha set at 0.05. Results were presented as medianpercentage change compared with control with 95% confidence intervalsfor difference of means.

In flexion-extension the ROM of the nucleotomy and implant groupincreased by 24% (CI 5% to 65%) and 12% (CI −6% to 30%) respectivelywhen compared to pretreatment. The NZ in the nucleotomy and implantgroup increased by 124% (CI 20% to 202%) and 0.5% (CI 7% to 31%)respectively when compared to pretreatment. In lateral bending, the ROMof the nucleotomy and implant group increased by 35% (CI 6% to 72%) and5% (CI −22% to 42%) respectively when compared to pretreatment. The NZin the nucleotomy and implant group increased by 69.8% (25% to 256%) and0.5% (CI −28% to 33%) respectively when compared to pretreatment.

Accordingly, in this study, there was an increase in motion segmentlaxity after nucleotomy during sagital and coronal movements offlexion-extension and lateral bending, which is reversed withimplantation of the exemplary device. The data suggests that theexemplary device can restore the biomechanical changes in a de-nucleatedmotion segment.

Additionally, an embodiment of the implant disclosed herein wasimplanted into a 41 year old male who presented with lower back pain for4½ years following a work related injury in 2003. He subsequentlyunderwent a posterior decompression surgery in 2005 which resulted inrelief of pain for a brief time but then continued to complain of backpain which he rates at 9 out of 10 and bilateral leg pain. He hadsignificant restriction of all activities of daily living and was takinghigh doses of narcotic analgesics to control his pain. He has no othermedical co-morbidities nor does he have any ongoing legal issues relatedto his work injury. A physical examination revealed a cooperative,pleasant gentleman who overall has good balance and station. Themovements of the thoracolumbar spine were painful and grossly restrictedin the sagittal plane. Lower limb neurology was nearly normal. Thestraight leg raising test was positive on the right side.

An MRI scan of the LS spine showed degeneration of the L4-L5 disc. Theadjacent discs appeared to be well hydrated. Radiographs of thelumbo-sacral spine showed normal alignment. The patient had no relief ofsymptoms following a whole range of non-operative treatment modalities,including physiotherapy and spinal injections. He was eventuallyconsidered for the procedure disclosed herein.

He underwent a partial nucleus replacement procedure on 27 Dec. 2007 andthe immediate post-operative period was uneventful. At the six week markafter surgery, the patient had about an 80% reductionin his back painand about a 90% reduction in his leg pain. He is presently undergoingphysiotherapy to increase his activity levels and the narcoticanalgesics are being tapered. The short term results have been veryencouraging.

In one of the embodiments, a polymeric material, more specifically anelastomer, and preferably a silicone, of a particular hardness is usedfor a nucleus prosthesis. The hardness of the material may be in therange of 1-20 A or 21-40 A or 41-60 A or 61-80 A or greater than 81 AShore Hardness, but preferably 25 A. Materials like silicones are wellsuited for a nucleus prosthesis application because it is a viscoelasticmaterial which means it is capable of providing the shock absorbingrequirements of the motion segment. Under a given load, the prosthesisdeforms and is capable of distributing the applied load radially toevenly distribute the load across the endplate and to the annulus. Thisreduces the risk of the implant subsiding into the endplates andrestores the intradiscal pressure which restores the hoop stresses tothe annulus. More importantly, the nucleus prosthesis is elasticallydeformable. Thus, the application of force will cause the nucleusprosthesis to deform elastically so that, once the force has beenremoved, the prosthesis will return to its relaxed, undeformed state

Therefore, some beneficial characteristics of the implant disclosedherein may include, for example, shock absorption, restore hoopstresses, provide required range of motion, restore biomechanics, withinthe required range of hardness (shore hardness) (less chance of implantsubsidence), using same class of materials results in homogeneity, fastcuring, substantially biocompatible, in mild to moderate discdegeneration the implant is not only load distributing but also loadbearing, substantially silicone, silicone composites, polyurethane,cellulose, collagen based, elastin based.

It will be appreciated by persons skilled in the art that numerousvariations and/or modifications may be made to the inventions as shownin the embodiments without departing from the spirit or scope of theinventions as broadly described. The present embodiments are, therefore,to be considered in all respects as illustrative and not restrictive.

1. An apparatus for use with a working cannula, said cannula beingconfigured to be fixedly docked percutaneously to an in situ implantsite, the apparatus comprising: a closed dispensing assembly includes adistal end magnetic mount for removably coupling said dispensingassembly to the working cannula and a proximal end magnetic mount forremovably coupling said dispensing assembly to a closed sizing assemblyduring an implant site size determination procedure and for removablycoupling said dispensing assembly to a closed insertion assembly inplace and stead of said dosed sizing assembly during an implantplacement and filling procedure; wherein said distal end magnetic mountfacilitates connecting and disconnecting said dispensing assembly fromsaid working cannula without relative rotational motion therebetween tohelp reduce tissue trauma to the patient; and wherein said proximal endmagnetic mount facilitates connecting and disconnecting said dispensingassembly from said dosed sizing assembly without relative rotationalmotion therebetween to further help reduce tissue trauma to the patientand to further facilitate connecting and disconnecting said dispensingassembly from said insertion assembly without relative rotational motiontherebetween to still further help reduce tissue trauma to the patient.2. The apparatus of claim 1, said closed sizing assembly is configuredto be partially received within said working cannula for carrying at adistal end thereof an elastically deformable mock implant member to thein situ implant site to facilitate determining without fluid evacuationfrom the dosed implant system a known volume of filler material tosubstantially fill a prosthesis implant to be formed at the implantsite; wherein said closed insertion assembly is configured to bepartially received within said working cannula in place and stead ofsaid dosed sizing system for protectively carrying an elasticallydeformable implant member to the in situ implant site to facilitate itsfilling with said known volume of filler material; and wherein saidclosed dispensing assembly is configured to be partially received withinsaid working cannula and removably coupled to said closed insertionassembly to facilitate the filling of the implant member with said knownvolume of filler material without fluid evacuation from the closedimplant system.
 3. A self contained dosed implant system for theformation of a prosthesis device percutaneously at an in situ implantsite, comprising: a single lumen working cannula, said working cannulaconfigured to be docked against an outer surface area of the in situimplant site; a closed sizing assembly configured to be partiallyreceived within a single lumen working cannula, said working cannulaconfigured to be docket at the in situ implant site for implanting theprosthesis device and said dosed sizing assembly for carrying at adistal end thereof an elastically deformable mock implant member to thein situ implant site to facilitate determining without fluid evacuationfrom the dosed implant system a known volume of filler material tosubstantially fill the volume of implant receiving cavity; a closedinsertion assembly configured to be partially received within saidworking cannula in place and stead of said closed sizing system forprotectively carrying an elastically deformable implant member to the insitu implant site to facilitate its filling with said known volume offiller material; a closed dispensing assembly configured to be partiallyreceived within said working cannula and removably coupled to said dosedinsertion assembly without relative rotational motion therebetween tofacilitate the filling of the implant member with said known volume offiller material without fluid evacuation from the closed implant system;and wherein said working cannula, said closed sizing assembly, saidclosed insertion assembly and said closed dispensing assembly areconfigured to be magnetically coupled to help reduce tissue trauma to apatient by obviating relative rotational coupling motions.
 4. A selfcontained closed implant system for the formation of a prosthesis devicepercutaneously within a nucleus cavity formed in an intervertebral discat an in situ implant site, comprising: a single lumen working cannula,said working cannula configured to be docketed against an outer surfacearea of an annulus surrounding the nucleus cavity; a closed sizingassembly configured to be partially received within said working cannulafor carrying at a distal end thereof an elastically deformable mockimplant member to the in situ implant site to facilitate determiningwithout fluid evacuation from the closed implant system a known volumeof filler material to substantially fill the volume of the nucleuscavity; a closed insertion assembly configured to be partially receivedwithin said working cannula in place and stead of said closed sizingsystem for protectively carrying an elastically deformable implantmember to the in situ implant site to facilitate its filling with saidknown volume of filler material; a closed dispensing assembly configuredto be partially received within said working cannula and removablycoupled to said closed insertion assembly without relative rotationalmotion therebetween to facilitate the filling of the implant member withsaid known volume of filler material without fluid evacuation from theclosed implant system; and wherein said working cannula, said closedsizing assembly, said closed insertion assembly and said closeddispensing assembly are configured to be magnetically coupled to helpreduce tissue trauma to a patient by obviating relative rotationalcoupling motions.
 5. The self contained closed implant system accordingto claim 4, wherein said single lumen working cannula has arranged atabout its proximal end a collar assembly to facilitate mockinglyengaging the working cannula with said closed insertion assembly; saidcollar assembly including: a cannula collar secured at a proximal end ofsaid working cannula; said cannula collar having a set of recesses tohelp facilitate the removal of a protective sheath surrounding theimplant member once it is placed within nucleus cavity; a push-offcollar removably secured to a proximal end of said cannula collar tohelp facilitate separating the implant member from the implant system;and a connector collar removably secured to a proximal end of saidpush-off collar for coupling said insertion assembly to said dispensingassembly without relative rotational motion therebetween to facilitatethe filling of the implant member with said known volume of fillermaterial without fluid evacuation from the closed implant system; andwherein said single lumen working cannula is configured with a pair ofoppositely disposed longitudinally extending slits dimensioned forslidably receiving therein a set of tabs extending outwardly from saidprotective sheath, said tabs being dimensioned to be received within theset of recesses disposed in said cannula collar to further helpfacilitate the removal of the protective sheath from the implant memberonce the implant member is placed within the nucleus cavity.
 6. The selfcontained closed implant system according to claim 4, wherein saidclosed insertion assembly includes: a single lumen carrier tube forcarrying at a distal end thereof the elastically deformable implantmember; a protective sheath extending over the elastically deformableimplant member for protecting it while being carried and placed withinthe nucleus cavity by said single lumen carrier tube; a stiffening roddimensioned to be slidably received within said carrier tube and havinga sufficient length extending between a distance beyond the distal endof the carrier tube to be received within the interior of theelastically deformable flow restricting implant member and anotherdistance beyond a proximal end of said working cannula to facilitatecollapsing the implant member onto a distal end of said stiffing rod;and a push off tube to facilitate the removal of elastically deformableflow restricting implant member from said carrier tube once filled withsaid known volume of filler material, said push off tube dimensioned tobe slidably received within said working cannula and for slidablyreceiving therein said single carrier tube; said push off tube havingarranged about its distal end the protective sheath, said sheathextending beyond a distal end of the elastically deformable flowrestricting implant member during its placement within the nucleuscavity; said push off tube having disposed at about its proximal end abayonet fitted collar dimensioned to be received within said cannulacollar to facilitate locking engagement between the single lumen workingcannula and the closed insertion assembly; and a magnetic mount coupledto a tube connector in fluid communication with said carrier tube tofacilitate coupling said closed insertion system to said closeddispensing system without relative rotational motion therebetween forfilling of the implant member with said known volume of filler materialwithout fluid evacuation from the dosed implant system.
 7. The selfcontained dosed implant system according to claim 4, wherein said closeddispensing assembly includes: a connector in fluid communication withthe implant member; a withdrawing device in fluid communication withsaid connector for increasing the volume of the dosed implant system tofacilitate collapsing the implant member and removing substantially allfluids therefrom so said implant member may be filed with said knowvolume of filler material without fluid evacuation from the closedimplant system; and a dispensing device in fluid communication with saidconnector for dispensing to a collapsed implant member said known volumeof filler material without fluid evacuation from the closed implantsystem.
 8. The self contained dosed implant system according to claim 7,wherein said closed dispensing assembly further includes a sensingarrangement for providing an indication that the implant member has beeninflated with a sufficient volume of filler material corresponding tosaid know volume of filler material; wherein upon said sensingarrangement providing said indication, said dispensing assembly may beimmediately removed from the working cannula without waiting for thefiller material in the implant member to cure.
 9. The self containedclosed implant system according to claim 8, wherein said dispensingassembly still further includes an occluding arrangement for occludingaccess to the inflated implant member concurrently with the immediateremoval of said dispensing assembly.
 10. The self contained dosedimplant system according to claim 4, wherein said closed sizing assemblyincludes: a tube having a single lumen for carrying the mock implantmember at a distal end thereof; a connector coupled at a proximal end ofsaid tube, said connector defining a primary lumen for fluidcommunication with said tube and a secondary lumen for fluidcommunication with said tube; at least one pressure transducer coupledfluid dispenser arrangement including a primary syringe connectable tothe primary lumen for fluid communication with said single tube and asecondary syringe connectable to the secondary lumen for fluidcommunication with said single tube; a fluid control arrangementdisposed at a proximal end area of said single tube operable to placeeither the primary lumen of the connector in fluid communication withthe tube or secondary lumen of the connector in fluid communication withthe tube; wherein said primary syringe is connectable to said connectorto be in fluid communication with said primary lumen, said primarysyringe having a barrel and a plunger slidably displaceable in thebarrel to facilitate the delivery and removal of a non-compressibleliquid to the mock implant member; wherein said secondary syringe isconnectable to said connector to be in fluid communication with saidsecondary lumen, said secondary syringe having another barrel andanother plunger slidably displaceable in said another barrel tofacilitate the delivery and removal of a compressible liquid to the mockimplant member; wherein said fluid control arrangement is operable in apriming step to occlude the fluid communication path between saidprimary lumen and the tube and to open the fluid communication pathbetween said secondary lumen and the tube to facilitate inflating saidmock implant member with compressible liquid dispensed from saidsecondary syringe and compressible liquid contained within the closeddelivery system; and wherein said fluid control arrangement is operablein another priming step to occlude the fluid communication path betweensaid secondary lumen and the tube and open the communication pathbetween said primary lumen and the tube to facilitate placing saidprimary syringe in fluid communication with said tube for inflating themock implant member with non-compressible liquid dispensed from saidprimary syringe, said primary syringe containing a sufficient volume ofthe non-compressible liquid to inflate said mock implant member to afully expanded state conforming to the shape of the cavity to provide anindication of said known volume of filler material to substantially fillthe volume of the nucleus cavity.
 11. The self contained dosed implantsystem according to claim 10, wherein the non compressible fluiddispensed from said primary syringe is heavier that the compressiblefluid dispensed from said secondary syringe; and wherein said heaviernon compressible fluid sinks to a distal end portion of the mock implantmember; and wherein the compressible fluid contained within the dosedimplant system collects at about a distal end of the tube.
 12. The selfcontained closed implant system according to claim 11, wherein said mockimplant member in its fully collapsed primed state points upwardly sincethe buoyancy of the compressible fluid within the closed sizing systemcauses the compressible fluid therein to disperse toward a distalportion of said mock implant member in close proximity to the singlelumen of said tube; and wherein said mock implant member in its fullyinflated state points downwardly during said priming step to facilitatean accurate measurement of the nucleus cavity.
 13. The self containeddosed implant system according to claim 12, wherein withdrawaldisplacement of said another plunger within said another barrel isprevented in the closed sizing system from extending beyond a zeroingposition when said mock implant member is in said fully collapsed stateand is extendable in an opposite displacement until a sudden increase inpressure resulting from the mock implant member becoming fully inflatedwith a sufficient volume of non-compressible liquid so the mock implantmember substantially conforms to the shape of the cavity.
 14. The selfcontained closed implant system according to claim 13, wherein saidsudden increase in pressure causes a transducer coupled to the plungerof said primary syringe to emit an enunciation.
 15. The self containeddosed implant system according to claim 14, wherein said enunciation isan audible enunciation indicative of an end point in filling the mockimplant member with non-compressible fluid.
 16. The self contained dosedimplant system according to claim 14, wherein said enunciation is avisible enunciation indicative of an end point in filling the mockimplant member with non-compressible fluid.